2011 NATIONAL REPORT (2010 Data)
TO THE EMCDDA
by the Reitox National Focal Point
IRELAND
New Developments, Trends and in-depth
information on selected issues
REITOX
Acknowledgements
Addiction service managers, drug treatment facilities and general practitioners
Central Statistics Office
Central Treatment List
Coroner Service
Customs Drugs Law Enforcement of the Revenue Commissioners
Department of Community, Equality and Gaeltacht Affairs
Department of Education and Science
Department of Health
Department of Justice and Law Reform
Department of Social Protection
Forensic Science Laboratory
Garda National Drugs Unit
General Mortality Register
Health Protection Surveillance Centre
Health Service Executive
Hospital In-Patient Enquiry scheme
Irish Prison Service
The Garda Síochána
Office for the Minister for Children and Youth Affairs
Voluntary and community groups and academic researchers
We would specially like to thank the following:
Dr Joe Barry, Ms Theresa Barnett, Ms Elaine Butler, Dr Des Corrigan, Ms Caroline
Comar, Mr Michael Conroy, Mr John Craven, Mr Niall Cullen, Ms Gretta Crowley, Mr
Niall Cullen, Ms Aileen Dooley, Mr Joe Doyle, Dr Brian Farrell, Ms Caroline Gardner,
Dr Justine Horgan, Mr Liam Hughes, Dr Pierce Kavanagh, Dr Eamon Keenan, Dr Alan
Kelly, Mr John Moloney, Ms Niamh Murphy, Dr Kate O’Donnell, Dr Dan O’Driscoll, Ms
Dairearca Ní Néill, Mr Brendan Ryan, Ms Susan Scally, Dr Bobby Smyth, Ms Sandra
Tobin, Dr Lelia Thornton and Professor Miriam Wiley.
Finally, we would like to express our sincere thanks to our Health Research Board
colleagues working in the area of alcohol and drug related research Fiona Bannon,
Delphine Bellerose, Anne Marie Carew, Mary Dunne, Louise Farragher, Ena Lynn,
Vivion McGuire, Deirdre Mongan, Joan Moore and Simone Walsh who provided
access to literature, analysed data from reporting systems or summarised literature for
Drugnet Ireland.
Brian Galvin
Head of the Irish Focal Point
This report was written by:
Johnny Connolly
Suzi Lyons
Martin Keane
Brigid Pike
Jean Long
This report was compiled by Mairea Nelson and Brigid Pike.
Please use the following citation:
Irish Focal Point (2011) 2011 National Report (2010 data) to the EMCDDA by the
Reitox National Focal Point. Ireland: new developments, trends and in-depth
information on selected issues. Dublin: Health Research Board.
2
Contents
Summary of each chapter................................................................................ 6
Main points from Part A........................................................................................................ 6
Main points from Part B ...................................................................................................... 11
Part A: New Developments and Trends........................................................ 13
1.
Drug policy: legislation, strategies and economic analysis....................... 13
1.1
Introduction ............................................................................................................. 13
1.2
Legal framework...................................................................................................... 14
1.2.1
Laws, regulations, directives or guidelines in the field of drug issues (demand
& supply) ....................................................................................................... 14
1.2.2
Laws implementation ...................................................................................... 16
1.3
National action plan, strategy, evaluation and co-ordination .................................. 24
1.3.1
National action plan and/or strategy ................................................................ 24
1.3.2
Implementation and evaluation of national action plan and/or strategy .......... 26
1.3.3
Other drug policy developments e.g. government declaration, civil society
initiatives........................................................................................................ 26
1.3.4
Co-ordination arrangements ............................................................................ 28
1.4
Economic analysis ................................................................................................... 29
1.4.1
Public expenditures ......................................................................................... 29
1.4.2
Budget ............................................................................................................. 29
1.4.3
Social costs ...................................................................................................... 30
2.
Drug Use in the General Population and Specific targeted-Groups .......... 31
2.1
2.2
2.3
2.4
3.
Introduction ............................................................................................................. 31
Drug use in the general population (based on probabilistic sample) ....................... 32
Drug use in the school and youth population (based on probabilistic sample) ....... 35
Drug use among targeted groups/settings at national and local level (university
students and conscript surveys, migrants, music venues gay clubs, gyms) ............. 36
Prevention ..................................................................................................... 39
3.1
Introduction ............................................................................................................. 39
3.2
Universal prevention................................................................................................ 40
3.2.1
School .............................................................................................................. 40
3.2.2
Family ............................................................................................................. 42
3.2.3
Community ...................................................................................................... 43
3.3
Selective prevention in at-risk groups and settings ................................................. 44
3.3.1
At-risk groups .................................................................................................. 44
3.3.2
At-risk families ................................................................................................ 46
3.3.3
Recreational settings (incl. reduction of drug and alcohol related harm) ........ 46
3.4
Indicated prevention ................................................................................................ 46
3.4.1
Children at risk with individually attributable risk factors (e.g. children with
AD(H)D, children with externalising or internalising disorders) .................. 46
3.5
National and local media campaigns ....................................................................... 48
4.
Problem Drug Use (PDU) .............................................................................. 50
4.1
Introduction ............................................................................................................. 50
4.2
Prevalence and incidence estimates of PDUs .......................................................... 50
4.2.1
Indirect estimates of problem drug use ........................................................... 50
4.2.2
Estimates of incidence of problem drug use ................................................... 53
4.3
Data on PDUs from non-treatment sources (police, emergency, needle exchange
etc) ........................................................................................................................... 54
4.3.1
PDUs in data sources other than TDI .............................................................. 54
4.4
Intensive, frequent, long-term and other problematic forms of use ......................... 56
4.4.1
Description of the forms of use falling outside the EMCDDA’s PDU definition
(in vulnerable groups) .................................................................................... 56
4.4.2 Prevalence estimates of intensive, frequent, long term and other problematic forms
of use, not included in the PDU definition .................................................... 56
3
5.
Drug-related treatment: treatment demand and treatment availability ...... 58
5.1
Introduction ............................................................................................................. 58
5.2
General description, availability and quality assurance........................................... 60
5.3
Strategy/policy ......................................................................................................... 60
5.4
Treatment systems ................................................................................................... 62
5.4.1
Organisation and quality assurance ................................................................. 62
5.4.2
Availability and diversification of treatment ................................................... 66
5.4.3
Access to treatment ......................................................................................... 70
5.5
Characteristics of treated clients (TDI data included) ............................................. 71
5.6
Trends in treated population and treatment provision (incl. numbers) .................... 77
6.
Health Correlates and Consequences ......................................................... 78
6.1
Introduction ............................................................................................................. 78
6.2
Drug-related infectious diseases .............................................................................. 79
6.2.1
HIV/AIDS and viral hepatitis .......................................................................... 79
6.2.2
STI’s and tuberculosis ..................................................................................... 80
6.2.3
Other infectious morbidity (e.g. abscesses, sepses, endocarditis, wound
botulism) ........................................................................................................ 80
6.2.4
Behavioural data.............................................................................................. 82
6.3
Other drug-related health correlates and consequences ........................................... 82
6.3.1
Non-fatal overdoses and drug related emergencies ......................................... 82
6.3.2
Other topics of interest e.g. psychiatric and somatic co-morbidity, traffic
accidents, pregnancies and children born to drug users ................................. 87
6.4
Drug-related deaths and mortality of drug users ..................................................... 93
6.4.1
Drug-induced deaths (overdoses/poisonings) ................................................. 93
6.4.2
Mortality and causes of deaths among drug users (mortality cohort studies) . 95
6.4.3
Specific causes of mortality indirectly related to drug use (e.g. HIV/AIDS and
HCV related to IDU, suicides, accidents) ...................................................... 96
7.
Responses to Health Correlates and Consequences ................................. 98
7.1
Introduction ............................................................................................................. 98
7.2
Prevention of drug-related emergencies and reduction of drug-related deaths ....... 98
7.3
Prevention and treatment of drug-related infectious diseases................................ 101
7.4
Responses to other health correlates among drug users ........................................ 103
7.4.1
Maternal and neonatal health among opiate users ......................................... 103
8.
Social Correlates and Social Reintegration............................................... 105
8.1
Introduction ........................................................................................................... 105
8.2
Social exclusion and drug use................................................................................ 105
8.2.1
Social exclusion among drug users ............................................................... 106
8.2.2
Drug use among socially excluded groups .................................................... 106
8.3
Social reintegration ................................................................................................ 109
8.3.1
Housing ......................................................................................................... 109
8.3.2
Education, training ........................................................................................ 112
8.3.3
Employment .................................................................................................. 113
9.
Drug-related crime, prevention of drug-related crime and prison ........... 115
9.1
Introduction ........................................................................................................... 115
9.2
Drug-related crime ................................................................................................. 117
9.2.1
Drug law offenses.......................................................................................... 117
9.2.2
Other drug-related crime ............................................................................... 119
9.3
Prevention of drug-related crime ........................................................................... 122
9.3.1
Drugs and driving .......................................................................................... 122
9.4
Interventions in the criminal justice system .......................................................... 122
9.4.1
Alternatives to prison .................................................................................... 123
9.4.2
Other interventions in the criminal justice system ........................................ 124
9.5
Drug use and problem drug use in prisons ............................................................ 124
4
10. Drug Markets ............................................................................................... 125
10.1 Introduction ........................................................................................................... 125
10.2 Availability and supply .......................................................................................... 126
10.2.1 Perceived availability of drugs, exposure, access to drugs e.g. in general
population, specific groups/places/settings, problem drug users ................. 126
10.2.2 Drugs origin: national production versus imported ....................................... 127
10.2.3 Trafficking patterns, national and international flows, routes, modi operandi;
and organisation of domestic drug markets ................................................. 127
10.3 Seizures.................................................................................................................. 136
10.3.1 Quantities and numbers of seizures of all illicit drugs .................................. 136
10.3.2 Quantities and numbers of seizures of precursor chemicals used in the
manufacture of illicit drugs .......................................................................... 139
10.3.3 Number of illicit laboratories and other production sites dismantled; and
precise type of illicit drugs manufactured there ........................................... 139
10.4 Price/purity ............................................................................................................ 139
10.4.1 Price of illicit drugs at retail level ................................................................. 140
10.4.2 Price/potency of illicit drugs ......................................................................... 140
10.4.3 Composition of illicit drugs and drug tablets ................................................ 140
Part B: Selected Issues ....................................................................................... 141
11. Drug-related health policies and services in prison ................................. 143
11.1
11.2
11.3
11.4
11.5
11.6
Introduction ........................................................................................................... 143
Prison systems and prison populations: contextual information .......................... 143
Organisation of prison health policies and service delivery .................................. 148
Provision of drug-related health services in prison (please provide methodological
information: information sources, method of data collection and analysis,
limitations) ............................................................................................................. 151
Service quality ....................................................................................................... 154
Discussion, methodological limitations and information gaps .............................. 155
12. Drug users with children (addicted parents, parenting, child care and
related issues) ..................................................................................................... 162
12.1 Introduction ........................................................................................................... 162
12.2 Size of the problem ................................................................................................ 162
12.2.1 Studies or data collection on the prevalence and characteristics of drug using
pregnant women and parents ....................................................................... 162
12.2.2 Studies or data collection on the physical, mental and other risks/harms among
drug using pregnant women / parents and their children ............................. 166
12.3 Policy and legal frameworks ................................................................................. 171
12.3.1 Policies addressing drug using parents / pregnant women and their children171
12.4 Responses .............................................................................................................. 172
12.4.1 Availability of responses addressing the needs of drug using parents/pregnant
women and their children............................................................................. 172
Part C ............................................................................................................. 179
13. Bibliography ................................................................................................ 179
13.1
13.2
13.3
List of references ................................................................................................... 179
List of relevant databases available on internet ..................................................... 192
List of relevant internet addresses ......................................................................... 192
14. Annexes ....................................................................................................... 193
14.1
14.2
14.3
14.4
14.4
14.5
List of Standard Tables and Structured Questionnaires used in text ..................... 193
List of tables .......................................................................................................... 193
List of figures......................................................................................................... 195
List of maps ........................................................................................................... 195
List of legislation ................................................................................................... 195
List of abbreviations .............................................................................................. 196
5
Summary of each chapter
This report, written following European Monitoring Centre for Drugs and Drug Addiction
(EMCDDA) guidelines,1 is divided into two parts. Part A is an overview of new
developments and trends in the drugs area in Ireland for 2008 and, in some cases, for
the first six months of 2009. These are covered under the following headings:
1. Drug policy: legislation, strategies and economic analysis
2. Drug use in the general population and specific targeted-groups
3. Prevention
4. Problem drug use
5. Drug-related treatment: treatment demand and treatment availability
6. Health correlates and consequences
7. Responses to health correlates and consequences
8. Social correlates and social reintegration
9. Drug-related crime, prevention of drug-related crime and prison
10. Drug Markets
Part B examines two specific issues considered to be important at an EU level. The
Selected Issues are:
11. Drug-related health policies and services in prison
12. Drugs users with children (addicted parents, parenting, child care and related
issues)
Main points from Part A
1. Drug policy: legislation, strategies and economic analysis
A number of new legislative measures were introduced during the reporting year. The
aim of the Criminal Justice (Community Service) (Amendment) Bill 2011 is to require a
court to consider imposing a community service order instead of a prison sentence in
cases where an offender stands convicted of an offence for which a sentence of up to
twelve months imprisonment would be appropriate. Most drug offenders serve
sentences of less than one year.
The government has committed itself to introducing a new roadside drug-testing
programme in response to driving under the influence of drug offences. The
government has also committed itself to reviewing mandatory sentencing laws in the
context of drug policy. This is particularly relevant in light of a recent Supreme Court
decision which overturned a ten-year drug conviction, thereby raising a number of
questions about the future application of mandatory sentencing laws. The Criminal
Justice (Psychoactive Substances) Act 2010, introduced to address the ‘head shop’
phenomenon, has been the subject of a number of academic articles and studies
during the reporting year, some of which have been highly critical of this approach to
the control of ‘legal’ highs.
Following a general election in February 2011, the new coalition government both
endorsed the Interim National Drugs Strategy 2009–2016 (NDS), including the
integration of drugs and alcohol strategies, and set out its own priorities in relation to
illicit drugs in its new programme for government. It has assigned responsibility for the
NDS to the Department of Health, which has not had lead responsibility for the drugs
issue since the early 1990s. Two drug-related units have been established in the
Department (replacing the Office of the Minister for Drugs) – a Drug Policy Unit to
oversee the implementation of the NDS, and a Drugs Programme Unit to manage the
Drugs Initiatives Programmes.
1
A copy of the EMCDDA guidelines is available from the EMCDDA website at www.emcdda.eu.int
The guidelines require each Focal Point to write its National Report in a prescribed format using standard headings and
covering each topic using a check list of items. This helps to ensure comparability of reporting across the EU.
6
Ireland’s total budgeted public expenditure on the illicit drugs issue in 2010 was
€260.296 million. Analysis using the UN’s Categories of Functions of Government
(COFOG) shows that approximately two-thirds of direct public expenditure was
associated with health-related functions of government, just over one fifth with justicerelated functions and one tenth with education-related functions.
2. Drug use in the general population and specific sub-groups
The results of the third all-Ireland general population drug prevalence survey showed
that the proportion of adults (aged 15–64 years) who reported using an illegal drug in
their lifetime (ever used) increased, by just over 3%, from 24% in 2006/7 to 27.2% in
2010/11. The proportion of young adults (aged 15–34 years) who reported using an
illegal drug in their lifetime also increased, by just over 4%, from 31.4% in 2006/7 to
35.7% in 2010/11. The proportion of adults who reported using an illegal drug in the
last year (recent use) remained stable, at 7.2% in 2006/7 and 7% in 2010/11. The
proportion of young adults who reported using an illegal drug in the last year also
remained stable, at 12.1% in 2006/7 and 12.3% in 2010/11. The proportion of young
adults who reported using an illegal drug in the last month (current use) was 5.3%. The
considerable increase in the proportions using any illegal drug at some point in their
lives was influenced by the facts that drug use in Ireland is a recent phenomenon and
that the population of lifetime and recent drug users in Ireland is relatively young.
Several small studies were published during the reporting year on drug use among targeted groups
including early school leavers, rural school children and third-level students.
3. Prevention
Regarding prevention in schools, a recent report suggests that most post-primary
schools have substance use policies in place, but little is known about these policies or
their implementation. A recent evaluation of the implementation of Social, Personal and
Health Education (SPHE) in primary schools includes an assessment of the quality of
learning from and teaching of SPHE and the views of parents and school principals.
Another study reports that the effectiveness of measures to tackle early school-leaving
remains in doubt.
Following participation in the Strengthening Families programme, families affected by
drug use in the family unit have self-reported improvements in a number of areas.
Innovative measures to target ‘hard-to-reach’ families of drug users have been
developed by the Family Support Network (FSN). A case-study of a local communitybased project highlights the merits of this approach in responding to the needs of
‘treatment resistant clients’.
Evaluation of drug prevention measures remains poor, particularly for assessing
outcomes and impacts. Most evaluations focus on administration, implementation and
coordination. This information highlights how measures are being updated and
improved rather than an examination of their impact. This limits both the scope and
quality of reporting.
4. Problem drug use (PDU)
A national 3-source capture-recapture (CRC) study, conducted in 2006, indicates that
problem drug use in Ireland has increased since the previous survey in 2001. The
major expansion of the national methadone treatment programme between 2001 and
2006 is the main reason for the inflation of the figures. The National Advisory
Committee on Drugs has commissioned an investigation into methods and data
sources which can be used to estimate the number of problem opiate and cocaine
users and the prevalence of problematic opiate and cocaine use in Ireland.
Three research reports are described in which the pattern of problem drug use among
three separate populations is discussed – users of Simon Community services in
7
Ireland in 2010, 100 opiate or methadone users living in a local drugs task force area in
Dublin using data collected from September 2007 until the end of 2008, with some
follow-up work in 2009 and people with HIV in 2005 (this comparative study asked
about tobacco and alcohol use as well as other drug use).
5. Drug-related treatment: treatment demand and treatment availability
Treatment provision remains at a similar level to 2010 although the HSE is seeking to
increase coverage in the south and west regions of the country. A National Drugs
Rehabilitation Framework has been approved and implementation will enhance the
provision of rehabilitation services by creating integrated care pathways with the cooperation of different care providers.
The first ever external review of the Methadone Treatment Protocol has been
completed and contains recommendations with regard to maximising treatment
provision and reviewing the efficacy of referral pathways, clinical governance and audit,
enrolment and training of GPs, urine testing, prescribing of methadone in Garda
(police) stations and data collection and analysis. The UK-based Quality Standards in
Alcohol and Drugs Services (QuADS) programme is now being rolled out to services in
Ireland.
Regarding the range of services, a pilot programme for community detoxification has
been extended outside Dublin with two separate protocols provided, for methadone
and for benzodiazepines. Training in cognitive behaviour coping skills training,
rehabilitation and brief interventions particularly for overdose and alcohol misuse are
being provided through the National Addiction Training Programme.
Regarding access to care, the number of continuous care clients attending methadone
treatment has steadily increased, from 3,681 in 1998 to 8,727 in 2010. Over the past
five years, approximately 800 new clients have started methadone treatment each
year, an increase of roughly 7.5% per annum.
Researchers have analysed subsets of participants and data from the ROSIE
longitudinal study on opiate treatment and published six new papers. The analyses
included the effect of treatment settings, treatment pathways and use of additional
drugs on treatment outcomes for opiate users. Other studies have examined the
clinical profile, treatment and prevalence of patients admitted with a diagnosis of overthe-counter opiate abuse; predictive factors for relapse among alcohol-dependent
clients with a dual diagnosis; and a joint analysis of data on both treated problem
benzodiazepine use and poisoning deaths where a benzodiazepine was implicated.
In 2010, the number of cases entering treatment was higher than in 2009. This may be
due to an increase in the number of services making returns to the NDTRS or it may
reflect a genuine increase in the number of cases entering treatment. The proportion
entering treatment for the first time declined in 2010. Opiates (mainly heroin) were the
most common main problem drug reported, similar to previous years. The number and
proportion of cases treated for cocaine dropped. The largest increase in 2010 was in
the number of cases reporting a headshop drug as their main problem substance.
6. Health correlates and consequences
At the end of 2010 there were 5,700 diagnosed HIV cases in Ireland, of which 26%
were probably infected through injecting drug use. A study of singleton births at a
maternity hospital in Dublin from 2000 to 2007 showed that 1% were to women who
were prescribed methadone at delivery, and that a higher proportion of methadoneexposed women were likely to test positive for hepatitis B, hepatitis C and HIV than
non-exposed women .
A study undertaken in a methadone treatment centre in Dublin found that 69% of study
participants had at least one abscess and 80% reported that they were hepatitis C
8
positive. Another study found that the prevalence of MRSA in the opiate-dependent
population in Dublin is low.
With regard to recorded presentation of deliberate self-harm to hospital emergency
departments in 2010, drug overdose was the most common form of deliberate selfharm reported. In 2006–2008, following the withdrawal of distalgesic from the Irish
market in 2005, the rate of intentional drug overdose (IDO) presentations to hospital
involving distalgesic was 84% lower than in the three years before it was withdrawn.
There was a 44% increase in the rate of IDO presentations involving other prescription
compound analgesics but the magnitude of this rate increase was five times smaller
than the magnitude of the decrease in distalgesic-related IDO presentations.
A series of recently published studies look at morbidity owing to cocaine use in Dublin,
the prevalence of attention-deficit hyperactivity disorder (ADHD) in adults attending
outpatient psychiatric services in north Dublin, and the co-existence of substance
dependence among patients attending health services, one in a Dublin hospital and
one among a population of university students presenting for any reason to primary
care. Several cases are reported with regard to psychiatric illness and physical
complications as a result of using substances purchased in head shops in Ireland,
including Butylone and MDPV, Methylone, Whack, Benzylpiperazine, Butylone, and
Mephedrone.
In 2009, the number of deaths owing to poisoning recorded in Ireland by the NDRDI
decreased slightly, to 203 deaths from 211 in 2008. This is the first decrease in the
number of deaths owing to poisoning since 2003. Opiates continued to be associated
with the majority of fatal overdoses in 2009. The number of deaths where cocaine was
implicated, alone or with another drug, decreased again in 2009.
In early 2011 at least six fatal heroin overdoses were reported by the Irish media. This
was reputed to be caused by a drought of heroin in December 2010, followed by the
arrival of a batch ‘high quality’ heroin into the country. The true extent, pattern and full
impact of this drought on poisoning deaths in Ireland will be reported in future annual
figures from the NDRDI.
7. Responses to health correlates and consequences
Recent efforts to reduce the incidence of drug-related deaths in Ireland have included
the issuing of guidelines on the safe dispensing of non-prescription products containing
codeine. In addition, an evaluation of the impact on non-fatal IDO presentations to
hospital emergency departments nationally of the withdrawal, as of January 2006, of
distalgesic, has shown that it has had positive benefits in terms of IDO presentations to
hospital in Ireland.
Three studies have been published to help improve the prevention and treatment of
hepatitis C (HCV). A qualitative study was undertaken among current and former
injecting drug users to find out more about what enables or prevents them engaging at
every level of HCV care. Multiple barriers were identified but facilitators were also
identified. A study of all referrals to an urban tertiary care liver centre for HCV
management tracked subsequent progress and identified the dropout rate at the
different stages. Reporting an ‘exceptionally high rate of dropout’, particularly in the
early stages, the study findings have led to the development of innovative approaches
to optimising HCV management. Finally, a study to measure the knowledge of and
attitudes towards HCV among nurses found that nurses working in public health
services and general practice require formal training in HCV care and management,
while nurses in the addiction services need to update their knowledge in certain areas.
The health of women, who had been prescribed methadone for the treatment of opiate
dependence, and their infants, was the subject of two separate studies. One found the
hospital based drug liaison midwife plays an important role. The other paper reported
9
that the outcomes for mothers prescribed methadone and their new infants were not as
good as those for other mothers and infants.
Two community-based initiatives are described. Programmes in one local drugs task
force area in Dublin are aiming to fill the gaps left after addiction, such as boredom,
isolation and depression. The Anna Liffey Drug Project, has issued a booklet providing
harm reduction information on psychoactive drugs – legal highs or otherwise.
8. Social correlates and social reintegration
Drug use among socially excluded groups, including people living in disadvantaged
communities, female sex-workers, members of the travelling community, homeless
people and early school-leavers, is discussed. The research reported varies in quality
and depth. Another study shows that early school-leaving and homelessness among
drug users reporting for treatment shows little change over the period 2005–2010,
suggesting that measures to tackle these problems are not having the desired effect.
Social reintegration for drug users remains an aspiration of national drug policy, with
the new government’s Programme for Government including three proposals to
progress the recommendations of the working group on rehabilitation.
A recent study of the feasibility of using the Housing First approach to provide secure
accommodation for drug users provides good-practice guidelines. The approach will be
piloted through the Dublin Housing First Demonstration Project. The Soilse drug
rehabilitation programme, which uses an individualised model of adult education,
demonstrates the development of recovery capital among individuals in recovery from
drug addiction. The Ready for Work programme assists homeless people to secure
employment, helps individuals to secure work placements, turn placements into jobs or
secure alternative employment
9. Drug-related crime, prevention of drug-related crime and prison
Criminal proceedings for the possession of drugs for personal use decreased in 2009
for the first time since 2004, and proceedings for drug supply also decreased
marginally in 2009, returning to the same level as 2007. Proceedings for the cultivation
or manufacture of drugs have continued to increase since 2005. It is unclear whether
this increase is due to a growth in the commission of such offences or to a sustained
concentration of law enforcement on detecting such offences. Between 2005 and 2009
the number of prosecutions for driving under the influence of drugs (DUID) increased
by more than 900%. This increase could either be due to an increase in the incidence
of DUID or the more likely possibility that targeted police activity in this area has
increased.
The intimidation of drug users and their families by those involved in drug supply has
been highlighted as an issue in the National Drugs Strategy 2009–2016 and also at
conferences during the last year. The Citywide Drugs Crisis Campaign has agreed to
facilitate the establishment of an Intimidation Working Group to develop responses to
the issue.
In July 2011, the Courts Service and the Health Service Executive agreed to extend the
catchment area for the Drug Treatment Court in order to encourage more offenders to
avail of this response to drug-related crime.
10. Drug markets
Data on garda drug prosecutions show that the trend in prosecutions for drug
possession decreased in most garda regions throughout the state in 2009, after a
steady increase since 2006. However, the proportion of prosecutions outside the
capital has increased significantly.
10
Two studies on drug markets are reported. An ethnographic study of drug use in a
Dublin community provides a useful insight into a local drug market involving a range of
both licit and illicit drugs. By highlighting the issue of polydrug use in a small
community, this study raises questions as to the nature of local drug supply and
demand and whether people specialise in particular substances.
The first national illicit drug market study is due to be published in early 2012. Carried
out in four locations (two urban, one suburban and one rural), the aims of the study
were to examine the nature, organisation and structure of Irish drug markets, to identify
the various factors which can influence the development of local drug markets and the
impact of drug dealing and drug markets on local communities, and to describe and
assess interventions in drug markets with a view to identifying what further
interventions are needed. The study shows that the full impact of supply reduction
activity cannot be assessed by measuring arrests and seizures alone or through proxy
measurements such as price and purity. Data on demand reduction, social, health and
community welfare indicators also need to be collected.
Between 2005 and 2007, the number of drug seizures increased, then decreased in
2008 and 2009. In 2010 the number of seizures appears to have levelled out. Since
2007, seizures of cocaine, heroin and ecstasy-type substances have declined
significantly, and the reduction in total drug seizures in 2009 can be attributed primarily
to a reduction in cannabis and cocaine seizures. The continued decline in heroin
seizures in 2010 may reflect a decline in heroin use or a change in law enforcement
activities or some other factor. Data on prison drug markets are reported for the first
time.
A study by the Forensic Science Laboratory on the THC content of a sample of
cannabis resin and herbal cannabis plants was published in 2011. Conducted in light of
a reported increase in the number of so-called ‘cannabis factories’, the study set out to
find whether the increased demand for cannabis herb was because there is a shortage
of resin or because there is more THC in cannabis herb.
Main points from Part B
11. Drug related health policies and services in prison
The profile of the typical drug-using prisoner in Ireland is single, aged between 14 and
30, male, living in the parental home, from a large and often broken family, having left
school before the legal minimum age of 16, unemployed, with his best-ever job having
been in the lowest socio-economic class. He will have a high number of criminal
convictions and a history of other family members being in prison; there is a high rate
of high rate of recidivism among these prisoners. The typical drug-using prisoner has
also experienced extreme social disadvantage, being from an area with a high
proportion of local authority housing and often with high prevalence of opiate drug use
and a high level of long-term unemployment.
The widespread availability of drugs in prison has been confirmed through data from
prison drug-testing, and reports from the Inspector of Prisons. A recent study by the
HRB on drug-related deaths post-release concluded that many of the deaths were
preventable and the findings support the need for an overdose prevention strategy.
Since the launch of the Irish Prison Service (IPS) drugs policy and strategy document,
Keeping drugs out of prisons, the provision of drug services in Irish prisons has
improved. The IPS is committed to achieving care equivalent to that available in the
community. Those presenting with problem opiate use are offered detoxification if it is
clinically indicated, or stabilisation on methadone and addiction counselling as
treatment options. The contracting-out of treatment services to addiction services
based in the community and to private consultants including pharmacists has also been
beneficial and has enhanced links between prison and community-based services.
11
Although there has been an improvement in the drug-related health policies and
services in Irish prisons in recent years, the effective delivery of these services and the
attainment of the goal of equivalence of care have been undermined because of severe
prison overcrowding. In such a context the therapeutic benefit of drug treatment can
become a secondary concern to the control and security priorities of the prison
environment. Equally, a lack of clarity of responsibility and coherence of delivery
hinders the provision of a seamless care service pre and post release and exposes
vulnerable people to preventable drug-related deaths.
12. Drugs users with children (addicted parents, parenting, child care and related
issues)
In 2006/7, just over 23% of all respondents to the all-Ireland general population drug
use prevalence survey who reported having ever used any illegal drug, and 4% who
reported having used any illegal drug in the last year, also reported that they had
dependent children aged 18 years or younger. Between 2003 and 2009, NDTRS data
showed that the proportion of drug users in treatment reporting that they lived with a
partner and children ranged between 10.2% and 10.8%, and the proportion reporting
that they lived alone with children ranged from 3.7% to 4.6%. A number of separate
studies, undertaken between 1992 and 2007 at two of Dublin’s maternity hospitals,
found that the prevalence of illicit drug use among pregnant women ranged between
1% and 4.57%.
While there has been one major empirical study of the impact of parental drug use on
children in Ireland, authors of other Irish research reports have indicated the need to
research what amount to ‘hidden populations’ of children whose parents use drugs and
to explore their particular experiences, vulnerabilities and risk profiles. These
researchers have also highlighted the need for specific policies and services targeting
these populations.
Statutory services in Ireland to ensure the welfare and protection of all children aged
under 18 years include guidelines which identify parental drug or alcohol use as a risk
factor leading to a welfare concern. In recent years delivery of these statutory services
has been found to be inconsistent and the delivery system is currently being revised
and strengthened. The need for adequate training for professionals implementing these
guidelines in situations where parents are drug users is highlighted in several Irish
research studies, in order to ensure these professionals are prepared and sufficiently
sensitive and responsive to what are often complex and always unique situations.
12
Part A: New Developments and Trends
1.
Drug policy: legislation, strategies and economic analysis
1.1
Introduction
The classification of drugs and precursors in Ireland is made in accordance with the
three United Nations conventions of 1961, 1971 and 1988. Irish legislation defines as
criminal offences the importation, manufacture, trade in and possession, other than by
prescription, of most psychoactive substances. The principal criminal legislative
framework is laid out in the Misuse of Drugs Acts (MDA) 1977 and 1984, and the
Misuse of Drugs Regulations 1988. The offences of drug possession (s.3 MDA) and
possession for the purpose of supply (s.15 MDA) are the principal forms of criminal
charge used in the prosecution of drug offences in Ireland. The Misuse of Drugs
Regulations 1988 list under five schedules the various substances to which the laws
apply.
The National Drugs Strategy (interim) 2009–2016 provides the implementation
framework for illicit drugs policy in Ireland (Department of Community Rural and
Gaeltacht Affairs 2009). The Strategy has an overall strategic objective, ‘To continue to
tackle the harm caused to individuals and society by the misuse of drugs through a
concerted focus on the five pillars of supply reduction, prevention, treatment,
rehabilitation and research’. Implementation is based on a ‘partnership’ approach,
whereby over 20 statutory agencies, multiple service providers and community and
voluntary groups work together in a nationwide network of regional and local drugs task
forces (DTFs) to deliver the Strategy, with the statutory agencies critical in terms of
core service provision. The Minister for Health has overall responsibility for the National
Drugs Strategy, and an Oversight Forum on Drugs (OFD), chaired by the Minister of
State for Primary Care within the Department of Health, and comprising senior
representatives of the various statutory agencies involved in delivering on the Strategy,
and representatives from the community and voluntary sectors, meets every quarter to
monitor progress and address any operational issues.
Priorities for public expenditure on the drugs issue are set out in the National Drugs
Strategy. Public funds are allocated by way of the annual parliamentary Estimates
process, which allocates funds to departmental Votes. Funding for regional or local
initiatives may be either directly from government agencies and funds such as the
Young People’s Facilities and Services Fund (YPFSF), administered by the
Department of Children and Youth Affairs (DCYA), or via the regional and local DTFs.
Funding by DTFs proceeds from ‘initial’ to ‘mainstreamed’ funding as follows:
 Initial funding: DTF projects are initially set up as pilot projects with funding provided
through the Drugs Initiative, administered by the Department of Health. The
government department or agency most closely associated with the nature of the
project acts as the channel of funding to the project during this pilot phase.
 Mainstreamed funding: after the pilot phase, each project is evaluated and a
decision taken with regard to mainstreaming it in the appropriate government
department or agency. Once a project is mainstreamed, the responsibility for the
funding of the project transfers to that department or agency and the Department of
Health is no longer involved. DTFs continue to have a monitoring role in relation to
mainstreamed projects.
Other public funding mechanisms include the Dormant Accounts Fund and the national
lottery. The statutorily-based Dormant Accounts Fund contains unclaimed monies
transferred by credit institutions and insurance undertakings. The Dormant Accounts
legislation provides that these funds may be allocated to projects and programmes
designed to alleviate poverty and social deprivation.
13
1.2
Legal framework
This update covers drug-related acts and bills of the Oireachtas introduced or
progressed during the reporting year. It also identifies new substances brought under
control within the terms of the Misuse of Drugs legislation. Subject to the obligations of
European Union membership as provided in the Constitution of Ireland, the sole and
exclusive power of making laws for the State is vested in the Oireachtas. The
Oireachtas consists of the President and two Houses, Dáil Éireann (House of
Representatives) and Seanad Éireann (Senate). Bills are proposals for new laws. They
are usually approved by a Minister or another member of the government.
Occasionally, a private member’s bill is proposed by a member of the opposition. Such
bills, because they have not originated in government, are less likely than governmentsponsored bills to become law. To become law, a bill must first be approved by both
the Dáil and the Seanad, although the Dáil can override a Seanad refusal to pass a bill.
Joint committees are groups of members of Parliament, including both government
members and members of the opposition, which discuss proposed legislation and
make recommendations for amendments to the Minister. Bills can be introduced in
either the Dáil or Seanad and there are five stages in considering a bill. The second
and third stages are considered the most important as they offer the fullest
opportunities to Members to discuss and amend the contents of the bill. Once the bill
has been passed by the Oireachtas, the Taoiseach (Prime Minister) presents it to the
President to sign into law, and then it becomes an Act.
Acts do not come into operation until a commencement order is issued in the form of a
statutory instrument. There are five main types of statutory instrument: orders,
regulations, rules, bye-laws and schemes. Statutory instruments have a wide variety of
functions. They are not enacted by the Oireachtas but allow persons or bodies to whom
legislative power has been delegated by statute to legislate in relation to detailed dayto-day matters arising from the operation of the relevant primary legislation. Statutory
instruments are used, for example, to implement European Council Directives and
delegate the powers of Ministers. Specified government ministers and other agencies
and bodies are authorised to make statutory instruments and several hundred
instruments are made annually. Notice of the making of the commencement order is
published in the Oireachtas newsletter Iris Oifigiúil.
Also considered below are relevant debates in the Oireachtas in relation to the impact
of drug-related legislation, court decisions where the judiciary have provided specific
interpretations of legislation and academic and/or research findings in relation to drugrelated legislation.
1.2.1
Laws, regulations, directives or guidelines in the field of drug issues
(demand & supply)
This update covers drug-related acts and bills of the Oireachtas introduced or
progressed between January 2010 and July 2011. It also identifies new substances
brought under control within the terms of the misuse of drugs legislation.
Acts relevant to drug offences January 2010–July 2011
The Communications (Retention of Data) Act 2011 requires service providers, those
engaged in the provision of a publicly available electronic communication service or a
public communication network by means of fixed line or mobiles or the internet to retain
data relating to fixed and mobile telephony for 1 year, and data relating to internet
access, internet email and internet telephony for 2 years, and provides for disclosure in
relation to the investigation of specified offences, including Customs offences.
The Criminal Justice (Public Order) Act 2011 prohibits harassment or intimidation of
members of the public by persons who engage in begging and confers powers on
members of the Garda Síochána to give directions to persons to desist from begging,
in certain circumstances such as where they are begging near cash machines or in
14
front of places of business. It also provides for a series of sanctions including fines and
possible imprisonment for breaches of the law.
The Road Traffic Act 2011 provides, in advance of provisions of Part 2 of the Road
Traffic Act 2010, which will come into force in late 2011(see below), for the amendment
to existing legislation to permit the early introduction of mandatory alcohol testing of
drivers of mechanically propelled vehicles in certain circumstances, including
involvement of road traffic collisions The Act also clarifies the position regarding
mandatory preliminary breath testing.
The Criminal Justice (Money Laundering and Terrorist Financing) Act 2010
provides for offences of, and related to, money laundering in and outside the State; and
gives effect to Directive 2005/60/EC of the European Parliament and of the Council of
26 October 2005 on the prevention of the use of the financial system for the purpose of
money laundering and terrorist financing.
The Criminal Procedure Act 2010 makes provisions for a modification of the rule
against double jeopardy in order to allow a person who has been acquitted of an
offence to be re-tried in circumstances where new and compelling evidence emerges
or where the acquittal is tainted owing, for example, to corruption or intimidation of
witnesses or jurors, or perjury. The rule against double jeopardy provides that no
person may be put at risk of being punished twice for the same offence. The legislation
applies to a number of drug-related offences.
The Road Traffic Act 2010 provides for a reduction in the blood alcohol content
(BAC) limit for drivers and also provides powers to assist the Garda Síochána in
forming an opinion as to whether a driver is under the influence of an intoxicant (drug
or drugs) and to carry out a preliminary impairment test on such drivers.
The Criminal Justice (Psychoactive Substances) Act 2010 was implemented in
response to the emergence of so-called ‘headshops’ selling so-called ‘legal highs’ (Irish
Focal Point 2010) (see Ireland’s National Report 2010: Chapter 1.2.1). The Act
includes the following provisions:
 Section 3 provides for the offences of selling, importing and exporting psychoactive
substances for human consumption. Section 3 (1) provides for the offence of selling
a psychoactive substance, knowing or being reckless as to whether it is being
acquired or supplied for human consumption.
 Section 4 creates the offence of selling an object, knowing that it will be used to
cultivate by hydroponic means any plant in contravention of s17 of the Misuse of
Drugs Act 1977. Hydroponic cultivation is the cultivation of plants in liquid
containing nutrients, without soil, and under controlled conditions of light,
temperature and humidity. This method of cultivation is known to be used for the
purpose of growing cannabis indoors.
 Section 5 provides for the offence of advertising a psychoactive substance or object
to which Section 4 applies.
 Section 7 provides that a Garda Superintendent (or higher) may serve a prohibition
notice on a person where he or she believes that the person is selling, importing or
exporting psychoactive substances for human consumption, selling objects for use
in cultivating by hydroponic means any plant.
 Section 20 provides that a person guilty of an offence under the Act is liable on
summary conviction to a fine of up to €5,000 or imprisonment for up to 12 months
or both, or on conviction on indictment to a fine or to imprisonment not exceeding 5
years or both.
Also, in relation to the ‘legal highs’ phenomenon, on 11 May 2010 the government
made the Misuse of Drugs Act 1977 (Controlled Drugs) (Declaration) Order 2010 (S.I.
199 of 2010), declaring a range of ‘legal highs’ to be controlled drugs. To give effect to
this decision, on the same day the Minister for Health and Children signed the Misuse
of Drugs (Amendment) Regulations 2010 (S.I. 200 of 2010), the Misuse of Drugs
15
(Designation) (Amendment) Order 2010 (S.I. 201 of 2010), and the Misuse of Drugs
(Exemption) (Amendment) Order 2010 (S.I. 202 of 2010).
Under these statutory instruments, approximately 200 individual ‘legal high’
substances, which had been on sale in ‘head shops’ and which included the vast
majority of products of public health concern, were declared to be controlled drugs.
They include broadly:
 synthetic cannabinoids (contained in SPICE products),
 benzylpiperazine (BZP) and piperazine derivatives (commonly known as ‘party
pills’),
 mephedrone, methylone, methedrone, butylone, flephedrone, MDPV (i.e.
cathinones, often sold as baths salts or plant food), and
 Gamma butyrolactone (GBL) and 1,4 Butanediol.
In addition, the Declaration Order made under the Misuse of Drugs Act 1977 includes
ketamine and tapentadol, substances that have legitimate uses as medicines but which
can be subject to misuse. The Declaration Order also covers certain narcotic and
psychotropic substances which Ireland is obliged to bring under control in order to
comply with the UN Single Convention on Narcotic Drugs and the UN Convention on
Psychotropic Substances.
Status of bills going through the Oireachtas
The status of bills with relevance to the drugs issue currently passing through either
Dáil Éireann or Seanad Éireann is summarised below in Table 1.2.1.1.
Table 1.2.1.1 Status of bills relevant to the drugs issue currently before the Dáil
Title and explanatory memorandum
Status
The Criminal Justice (Community Service) (Amendment) Bill 2011
Final Stage
(No 12 of 2011) The primary purpose of this bill is to introduce a
27/06/2011
requirement on a court, before which an offender stands convicted of an
Passed by both Houses of
offence for which a sentence of up to twelve months imprisonment would
the Oireachtas
be appropriate, to consider imposing the alternative sentence of a
community service order. Although the Bill does not mention specific
offences, many offenders whose offences are committed as a
consequence of drug addiction receive short custodial sentences and
could benefit from the terms of this legislation.
The Spent Convictions Bill 2011 (No 15 of 2011) is intended to apply
First Stage
where certain convictions (a prison sentence not exceeding six months or
Introduced
a fine have been imposed) may be regarded as spent for certain
11/05/2011
purposes where the convicted person has not been convicted of any
other offence within a specified period of years. The purpose of the Act is
to help rehabilitate convicted persons through facilitating their
reintegration into the workforce and allowing them to build new careers.
The Criminal Justice Bill 2011 (No 16 of 2011) provides for changes to
First Stage
police powers to detain suspects for questioning. The amendments will
11/05/2011
allow the period of detention under section 4 of the 1984 Criminal Justice
Act to be suspended and the person released during the period of
suspension. The purpose of these provisions is to allow the Gardaí to
follow up on information obtained during initial questioning and so might
be of use in the investigation of particularly complex cases.
Pharmacy guidelines on safe supply of codeine-based products
The Pharmacy Act 2007 and the Regulation of Retail Pharmacy Businesses
Regulations 2008 require that all codeine-based products are dispensed under the
supervision of a pharmacist, and that individuals in receipt of the product should
receive appropriate counselling. See Chapter 5.5.2 for an account of recent Irish
research on inpatient treatment for over-the-counter (OTC) opiate misuse, and Chapter
7.2.2 for an account of the guidelines on the safe dispensing of non-prescription
products containing codeine, published by the Pharmaceutical Society of Ireland in
May 2010 (The Pharmaceutical Society of Ireland 2010).
1.2.2
Laws implementation
Programme for Government
16
The new programme for government, Government for National Recovery 2011–2016
(Fine Gael and the Labour Party 2011), contains a number of actions related to criminal
justice and drugs policy. Individual actions are listed below in italics, together with
commentary on their implementation or associated issues.
Roadside drug testing
We will introduce roadside drug testing programmes to combat the problem of driving
under the influence of drugs.
The development of reliable roadside testing procedure has been a challenging issue
for many countries. At present the Garda Síochána, the Department of Transport and
the Medical Bureau of Road Safety are collaborating in the development of a scheme
to introduce US-style roadside tests for suspected drug drivers to accompany roadside
alcohol tests.
Community service orders legislation
We will ensure that violent offenders and other serious offenders serve appropriate
prison sentences while at the same time switching away from prison sentences and
towards less costly non-custodial options for non-violent and less serious offenders.
This action provides the context for the introduction of the Criminal Justice (Community
Service) (Amendment) Bill 2011 described above in Section 1.2.1.
Mandatory sentencing laws for specific drug offences
A review will be conducted of the working of the mandatory sentencing laws in the
context of an overall review of drugs policy.
Sections15A and 27 of the Misuse of Drugs Act 1977 (as amended) provide for a
minimum presumptive sentence of ten years’ imprisonment for possession of drugs
with a market value of €13,000 or more.
A recent decision by the Supreme Court in Director of Public Prosecutions v Connolly
raises a number of important issues in relation to the future application of the
mandatory sentencing laws for specific drug offences (Courts Service judgments
2011). (Fine Gael and the Labour Party 2011) The Supreme Court quashed a previous
conviction under s.15A on the basis that the burden of proof required to determine the
purity and therefore value of the drugs had not been met by the prosecution. What
follows is an abridged summary of the judgement setting aside the conviction delivered
by Mr Justice Fennelly in the Supreme Court on 15 February 2011.
In the original trial it was alleged that the appellant in this case had in his possession
for the purpose of sale or supply amphetamines with a market value of €13,000 or
more contrary to section 15A (as inserted by section 4 of the Criminal Justice Act,
1999) and section 27 (as amended by section 5 of the Criminal Justice Act, 1999) of
the Misuse of Drugs Act 1977. This offence attracts a minimum presumptive sentence
of 10 years’ imprisonment. Counsel for the appellant submitted at trial that the proof of
value of the drugs proffered by the prosecution was insufficient and that he had no
case to answer. The trial judge refused his application for a direction. The appellant
appealed against his conviction to the Court of Criminal Appeal on the single ground
that:
there was no evidence on which a properly directed jury could come to the
conclusion and be satisfied beyond a reasonable doubt that the market value of
the drugs concerned was €13,000 or more.
The Court of Criminal Appeal (CCA) concluded that there had been no error of law in
the original trial. However, the CCA referred the following matter to the Supreme Court
to be determined as a question of law of exceptional importance:
In a prosecution pursuant to section 15A of the Misuse of Drugs Act 1977, for
the purpose of ascertaining the amount of a controlled substance present in a
powder in a sealed container or in a number of such containers proven by
expert evidence to contain that particular controlled substance, may the amount
17
of that controlled substance present in the powder be established by the oral
evidence of an expert as to the range within which amounts of that controlled
substance in other powders generally fell and, if the answer is in the affirmative,
must the prosecution disclose to the defence a statement or a report by that
expert setting out the facts upon which her or his opinion as to that range is
based?
The primary issue considered by the Supreme Court was the sufficiency of proof
required to determine the value of drugs. The appellant had been arrested in
possession of approximately 10kg of amphetamines packed in 10 separate bags. At
trial, a member of the Garda National Drugs Unit (GNDU) estimated the value of the
drugs at €145,755, using a price of €15,000 per kilo. The Garda assumed that each of
the packs of amphetamines contained at least 10% of amphetamine. It was accepted
that proof of the actual contents and percentage of amphetamine present was a matter
to be determined by the Forensic Science Laboratory (FSL).
A scientist of the FSL explained that she had analysed five of the packs and could say
with 100% certainty that the five packs contained amphetamine, but not how much.
She added that, taking into account the general appearance of the packs and the
powder, her professional opinion was that it was highly unlikely that any of the packs
would be negative. However, she stated further:
I can’t say for definite what the purity of the samples are but I can give a range
in which amphetamine purities generally fall between that is maybe 10 and 40%
but the samples were not quantified because quantification is not a routine
course of qualitative analysis so I cannot put an exact figure on the purity…
In further cross-examination, the scientist agreed that the presence of as little as 1%
would trigger the test she had carried out, but repeated that the range is generally
between 10% and 40%.
In his judgement, Mr Justice Fennelly explained the nature of the proof required to
secure a conviction under the relevant legislation.
Proof of value is an essential ingredient of the offence under section 15A. It is what
distinguishes it from the offence of possession for sale or supply of an unquantified and
unvalued amount of drugs. Most importantly, it is what has caused the Oireachtas,
subject to exceptional mitigating circumstances, to mark the offence as one of extreme
seriousness such as to require the court, in sentencing a convicted person, to impose a
penalty of a minimum of ten years’ imprisonment. The ingredient of value must be
proved to the satisfaction of the jury beyond reasonable doubt. At the original trial, the
forensic scientist established the presence of amphetamine in each of the five packs
she had analysed, but had not determined the extent of the amphetamine content and
was therefore unable to say ‘for definite’ what the level of presence of amphetamine
was. She said that the range in which amphetamine purities ‘generally fall’ was
between 10% and 40%.
Everything turns on the meaning to be attributed to the word ‘generally’. It is a word of
flexible use. It may imply, perhaps, that a majority of cases fall within that range, but, in
a weaker sense, may mean no more than ‘commonly’. If the facts were that analysis of
seized drugs for amphetamine always or nearly always falls within the 10/40% range,
one might have expected the witness to say so. Instead, she used the word ‘generally’
three times. In its normal usage the word leaves open the very real possibility that there
are cases outside that range. It cannot be assumed that Dr Casey (the scientist) meant
any more than that there was probably 10% to 40% amphetamine present. Probability
is not enough.
The evidence did not exclude the very real possibility that the percentage of
amphetamine present could have been as low as 1%. Such a percentage was
18
sufficient to produce the result which she obtained from her test. However, if that were
the case the value of those drugs would be less than the amount required to sustain a
conviction for the offence in issue. The proof of value is an objective matter. In this
case it was not sufficient for the prosecution to prove the mere presence of
amphetamine and to rely on an unexplained range of values which generally applies
without evidence which addressed the extent to which there are cases outside the
range. This left a gap in the prosecution evidence. I believe that the case should have
been withdrawn from the jury. I would allow the appeal and set aside the conviction of
the appellant in respect of count number 1 on the indictment. I would not direct a retrial.
There is no reason to believe that Dr Casey would be in a position to give any different
evidence on another occasion.
Criminal assets legislation
The new Programme for Government (Fine Gael and the Labour Party 2011) makes a
commitment to strengthen criminal assets seizure legislation at local level.
We will strengthen the supply reduction effort and criminal assets seizures, particularly
at local level.
During the last Dáil, the Labour Party introduced the Proceeds of Crime (Amendment)
Bill 2010 (Irish Focal Point 2010) (Chapter 1.2.1). The purpose of the Bill was to reduce
from seven years to two years the waiting period before the Criminal Assets Bureau
can apply to the High Court for the disposal and forfeiture of assets frozen under s.3 of
the Proceeds of Crime Act 1996. This Bill lapsed with the dissolution of the Dáil. The
Labour Party’s election manifesto, however, is committed to reintroducing this Bill, and
to the strengthening of drug supply reduction efforts and criminal assets seizure at a
local level. To date no legislation on this issue has been forthcoming.
Responding to a question in the previous Dáil, in relation to re-investing assets seized
back into local communities most affected by the drugs issue, the former Minister for
Justice, Dermot Ahern TD outlined the position of the then government on the issue.
The former Minister stated (Ahern, Dermot 2010, 17 November):
The issue of the proceeds of crime seized by the Criminal Assets Bureau being
used to fund community projects and drug services in disadvantaged
communities has been raised from time to time. …While it is accepted that
there may be some potential symbolic value in the suggestion nonetheless the
proposal is one which is problematic and raises a number of particular
difficulties. Revenue which has been accumulated by the Criminal Assets
Bureau is paid into the Government’s Central Fund. The Central Fund is
provided for under Article 11 of the Constitution. This fund, except where
provided otherwise by law, is the destination of all State revenues and the
source of all Government spending. It is the Central Fund from which the
Government draws for expenditure on all necessary public services and
investment including the provision of drug services. With certain exceptions, it is
believed that earmarking revenues for a specific expenditure programme would,
in general, constrain the Government in the implementation of its overall
expenditure policy. Furthermore, if certain revenues were earmarked for
particular projects any projects thus funded would be dependent on actual
revenue collected from that source. Therefore, a fall in revenue generated by
that source could imply a fall in expenditure on such projects. Given the variable
and uncertain nature of the value of the assets seized by the Bureau in any
given year, in addition to the potential delays through the possibility of legal
challenge to court disposal orders, the provision of ongoing funds to drug
programmes or projects in this manner would be problematic. Such a revenue
source would not facilitate the proper planning of drug treatment provision or
other such programmes by organisations involved in the delivery of services. It
could also be said that a significant proportion of the monies secured by the
Bureau are already owed to the Exchequer as it often relates to non-payment of
19
taxes and social welfare fraud. In the case of drugs services the Government is
already allocating very considerable resources to a wide range of Government
Departments and State agencies as well as to the community and voluntary
drug treatment sectors to tackle the issue of drug misuse. There is currently no
plan to change the existing arrangements concerning revenue accumulated by
the Criminal Assets Bureau.
In response to a further parliamentary question on a related matter, the current Minister
for Justice, Alan Shatter TD, stated the following (Shatter 2011, 17 May):
A dedicated unit within the Garda National Drugs Unit has been established to
liaise with the Criminal Assets Bureau to particularly target those criminals and
criminal groups believed to be deriving profits and assets from drug-related
criminal activity. In addition, the Criminal Assets Bureau continues to utilise the
services of criminal assets profilers located in Garda Divisions throughout the
country. …The role of the Criminal Assets Bureau in tackling those involved in
drug dealing, and the Bureau’s focus on middle and lower ranking criminals,
was acknowledged during the public consultation process which informed the
development of the National Drugs Strategy 2009-2016.
Drug treatment court
The Programme for Government includes a commitment in relation to the Drug
Treatment Court, particularly in relation to young offenders.
We will carry out a full review of the Drug Treatment Court programme to evaluate its
success and potential in dealing with young offenders identified as having serious
problems with drugs.
For a detailed discussion on the Drug Treatment Court, see Chapter 9.4.1 below.
Medicinal cannabis
In July 2010 medicinal cannabis was the subject of a response to a written question in
Dáil Éireann. The then Minister for Health and Children, Mary Harney TD, outlined the
position of the Government on the issue at that time when she stated: ((Reilly, James
2010, 6 July)
The current legal position in Ireland in relation to cannabis and cannabis based
medicinal products such as Sativex is that they are Schedule 1 controlled
substances under the Misuse of Drugs Act 1977. All Schedule 1 substances
are substances which are considered as having no medicinal use and the
manufacture, production, preparation, sale, supply, distribution and possession
of cannabis and cannabis derivatives is unlawful except for the purposes of
research. My Department is aware that claims have been made in respect of
Sativex and its possible benefits for patients suffering from certain conditions
such as Multiple Sclerosis and cancer. As the law currently stands it would not
be possible for Sativex to be licensed here for medicinal use or for a General
Practitioner to prescribe it.
The Minister went on to state that she was seeking expert clinical advice on the
matter. To date, no further information has been forthcoming and no further action has
been announced by the new government.
Legislation to control new psychoactive substances
The introduction of Misuse of Drugs Act 1977 (Controlled Drugs) (Declaration) Order
2010 (S.I. 199 of 2010), which declared a range of ‘legal highs’ to be controlled drugs
and the enactment of the Criminal Justice (Psychoactive Substances) Act 2010 in
August 2010, discussed above in Section 1.2.1, have had a clear impact on the ‘head
shop’ and ‘legal high’ phenomena. A number of commentators have also referred to the
impact and merits of these legislative attempts to curb the supply and use of ‘legal
highs’.
20
A Garda inventory of ‘head shops’ in Ireland indicated that, at their peak in early 2010,
there were 113 ‘head shops’ in the country, with at least one in every county. On 11
May 2010, when the government banned a range of ‘head shop’ products, there were
102 shops, 11 having already closed for various reasons. On 12 May 2010 the gardaí
visited all ‘head shops’ and warehouses and seized all banned products. By 13 May
there were 34 ‘head shops’ selling psychoactive substances, and in early August 2010
the number had increased to 39 shops. Following the enactment of the Criminal Justice
(Psychoactive Substances) Act 2010, the gardaí visited head shops in early September
2010 and found only 19 open and none selling psychoactive substances (Garda
Síochána, personal communication, 2010).
Notwithstanding these measures, a number of new substances have been identified in
‘head shop’ products by specialists at Trinity College Dublin and the Dublin Drug
Treatment Centre Board (Kavanagh, et al. 2010). They include the following:
 Dimethocaine, also known as larocaine, is a local anesthetic with stimulant
properties that are nearly as potent as those of cocaine.
 AM-694 is a drug which acts as a potent and selective agonist for the cannabinoid
receptor.
 Glaucine is an alkaloid found in several different plant species. It has bronchodilator
and anti-inflammatory effects and is used as a cough suppressant in some
countries.
 Phenethylamine (PEA) is a natural monoamine alkaloid and a psychoactive drug
with stimulant effects.
 Metamfepramone, also known as dimethylcathinone, dimethylpropion, or
dimepropion, is a stimulant drug.
 Synephrine is the main active compound found in the bitter orange which is an
extract of a plant called Citrus aurantium. It is a stimulant that constricts the blood
vessels, and increases heart rates.
 Mitragynine, an opioid agonist, is a stimulant at low doses and a painkiller or
sedative at higher doses.
 Hordenine occurs in a variety of grassy plants and grains, and in some species of
cactus. It stimulates the release of norepinephrine.
 L-dopa (levodopa) is a naturally occurring dietary supplement and psychoactive
drug found in certain kinds of food and herbs.
Responding to a parliamentary question on the impact of the legislation, the former
Minister for Justice, Equality and Law Reform, Dermot Ahern TD, stated (Ahern,
Dermot 2010, 08 July):
Following the regulation of certain psychotropic substances on 11 May 2010 under the
Misuse of Drugs Acts, and as part of Operation Kingfisher under the direction of the
Garda National Drugs Unit, members of An Garda Síochána in each Garda District
throughout the State visited every Head Shop to investigate their activity. As part of this
Operation, Gardaí took into possession all cannabanoid products, controlled cathinone
substances and any substances suspected to contain benzylpiperazine or its
derivatives. The total amount of substances involved was in excess of 4.5 tonnes. As a
result of the legislative measures introduced on 11 May a considerable number of head
shops across the country have already closed down with Garda National Drug Unit
records showing as on 14 June 2010 that a total of 44 head shops remain in operation
nationwide. In addition to the initial Garda visits to all head shop outlets on 12 May
2010, the Garda National Drugs Unit and local Drug Units continue to visit the
remaining outlets on an ongoing basis to conduct test purchasing of substances and to
monitor their activities. No arrests have been made to date arising from this but
prosecutions will be pursued in cases where any controlled drugs are detected in the
products sent for analysis.
The former Minister for Health, Mary Harney TD, stated further in response to the
infringement of medicinal products legislation by ‘head shops’ (Harney 2010, 08 July):
21
Certain products available in head shops have been reported to have
anaesthetic effects and therefore may be considered to fall within the scope of
the medicinal products legislation. Any such product is considered to be an
unauthorised medicinal product and, accordingly, the Irish Medicines Board has
been taking action to have these products removed from the market.
Additionally, the substances Fluorotropacocaine, which is contained in the
product WHACK, and Dimethocaine, which is contained in the product
AMPLIFIED, are considered to be medicinal products and as such they are
enforced by the Irish Medicines Board. These substances are not listed in the
Misuse of Drugs (Amendment) Regulations 2010 (S.I. No. 200 of 2010). The
Irish Medicines Board has visited 30 Head Shops in relation to these products.
Of these, one outlet was found to have the product WHACK and another was
found to have the product AMPLIFIED. Six outlets had products that were found
or suspected to contain substances with anaesthetic effect. The products
concerned include RAZ, Snowblow, Pure NRG, Ivory Wave, Sextacy and White
Ice and are suspected to contain the active pharmaceutical substance,
Lidocaine (also known as Lignocaine). 15 of the outlets have also been found to
be supplying other medicinal products for abuse purposes. These mainly
involved substances that are contained in prescription-only medicinal products
for erectile dysfunction.
Under the Irish Medicines Board Act 1995, as amended, the sanctions available to the
Irish Medicines Board (IMB) are the following:
A person who contravenes a regulation under section 32 of the Act shall be
guilty of an offence and shall be liable
(a) on summary conviction, to a fine not exceeding €2,000 or imprisonment for
a term not exceeding one year or a combination of both,
(b) on conviction on indictment
(i) in the case of a first offence, to a fine not exceeding €120,000 or
imprisonment for a term not exceeding 10 years or a combination of
both,
(ii) in the case of any subsequent offence, to a fine not exceeding
€300,000 or imprisonment for a term not exceeding 10 years or a
combination of both.
The former Minister told the Dáil that the IMB was currently finalising its investigations
in these cases that it had initiated prosecutions against four companies and one
individual (Harney 2010, 08 July).
Prior to the introduction of the legislative control of mephedrone, Van Hout and
Brennan (Van Hout, Marie Claire and Brennan 2011) conducted a study aimed at
exploring and uncovering a ‘consumptive snapshot of mephedrone use among prelegislation Irish users, with specific focus on user experiences, social situatedness of
mephedrone use and lay mephedrone risk and legality discourses’ (p. 2).Twenty-two
in-depth interviews were undertaken with young Irish people aged 18–35 years, who
had used mephedrone in the six months prior to fieldwork. Analysis of the resulting
narratives identified unique mephedrone-user decision-making processes, particular
drug effects and outcomes, socially contextualised mephedrone use and harmreducing strategies grounded in prior illicit and polydrug taking careers. With regard to
perceptions of risk and legality, the study found that ‘mephedrone was deemed a safer
alternative than illicit street drugs, as the drug outcome was observed by all
participants to be reliable in terms of potency, quality and perceived purity’ (p. 7). The
majority of participants observed mephedrone as inferring a ‘safer high’ owing to its
placement in ‘head shops’, with others acknowledging the lower cost and general
availability of mephedrone as increasing appeal of use. The authors report that
although mephedrone was legal at the time of the study, ‘it appeared that mephedrone
user experiences, reliability and positive effects, weighed far heavier than fears of
illegality’ (p. 9). They conclude that ‘the solitary focus on criminalisation of
mephedrone…inherently neglects to include user experiences centralised in
22
acceptable drug consumptive behaviours and internally sanctioned safe use in
weekend socialising’ (p. 9).
A number of academic articles have also questioned the rationale behind the recent
legislative approaches to controlling the ‘legal high’ phenomenon. Reuter (Reuter
2011), in a review of international approaches to responding to new psychoactive
substances, is extremely critical of the approach taken in Ireland. In criticising the
regulatory impact analysis conducted by the Department of Justice, Equality and Law
Reform (Department of Justice Equality and Law Reform 2010b), which accompanied
the legislation and included a cost-benefit analysis of the legislation, Reuter states that
the approach adopted was of ‘limited conceptual sophistication’ and ultimately naïve:
Consider for example Ireland, which has been active in the field. It has
published an analysis of regulatory options for head shops, which are prominent
there. The assessment makes no mention of any potential adverse effects of
prohibition. It identifies the dangers of not regulating and the potential gross
gains of the regulatory options. The only negative aspects of regulation that are
given any attention are the costs of operating the regulation. It is naïve
compared to, for example, environmental regulatory analysis, which requires
much more careful balancing of costs and benefits of each option. (p. 7)
In a similar vein, Ryall and Butler (Ryall and Butler 2011) set the controversy over
‘head shops’ in Ireland and the resulting legislation within the framework provided by
the sociological concept of ‘moral panic’. They describe this as a formulation of social
policy whereby, in this instance, ‘the negative societal consequences of psychoactive
drug use tend to be exaggerated – by the media and a range of other “moral
entrepreneurs” – thereby serving to legitimate extreme policy responses which,
paradoxically, may amplify the very deviance they were intended to curtail’ (p. 304).
Based on semi-structured interviews with some of the main stakeholders in this
process and set against a background of saturation media coverage of this
phenomenon, this article presents and assesses competing perspectives on the ‘head
shop issue’. On the one hand, from a conventional drug control perspective, recent
legislative measures in Ireland may, they suggest, be seen as representing effective
cross-cutting activity between the health and criminal justice sectors. From a harm
reduction perspective, on the other hand, the policy response may be seen as an
example of moral panic in that media portrayals greatly exaggerated the ill effects of
head shop products, in the process stoking public anger rather than encouraging
rational debate. Although the authors acknowledge ‘a degree of sophistication on the
part of all those interviewed’ (p. 310), including ‘head shop’ owners, users, law
enforcement personnel, policy advisors and the minister responsible for the drug
strategy at the time, ultimately they conclude that ‘the great head shop controversy
ended in a clear victory for traditional “war on drugs” values’ (p. 310).
More recently, the National Advisory Committee on Drugs published a study on new
psychoactive substances and the outlets supplying them (Kelleher, Cathy, et al. 2011).
The review, conducted between May and August 2010, sought to assess the
availability and accessibility of new psychoactive substances in retail outlets throughout
Ireland and online. With regard to the impact of new legislative measures the study
made a number of important findings.
Analyses of products purchased in head shops and online detected the emergence of
five new substances after the Misuse of Drugs Act 1977 (Controlled Drugs)
(Declaration) Order of May 2010: dimethylcathinone, naphyrone, fluorotropacocaine,
desoxypipradol and dimethylamylamine. A comparison of substances identified before
and after the May 2010 Order indicates that ‘suppliers moved quickly to replace
controlled substances with new uncontrolled substances’ (p. 74). Five products
purchased online from head shops as part of the study found that all contained
controlled substances including mephedrone. This led the authors to conclude that
‘head shops may respond to local control measures more quickly than they may do
23
with international online suppliers’ (p. 74). Further analysis found a lack of consistency
in the substances contained in what appeared, and were advertised, to be the same
product, even where products were purchased only a few days or weeks apart. This
finding has implications for consumers ‘including the potential for misuse, adverse
reactions and possible overdose’ (p. 74). In general, the authors observe that as a
consequence of the May 2010 Order and the Criminal Justice (Psychoactive
Substances) Act, which came into effect on 23 August 2010, the vast majority of ‘head
shops’ were closed, although ten have since reopened, selling ‘pipes, bongs and
clothing’. According to the study, ‘None are selling psychoactive substances and only
one…was observed to have hydroponic equipment on display’ (p75).
The authors conclude with a number of speculative observations as to the impact of the
Criminal Justice (Psychoactive Substances) Act 2010. These include the following (p.
79):
 It has already resulted in a rapid and marked decrease in the number of head
shops nationwide.
 It is likely that there will be a concomitant decrease in the use of psychoactive
substances by casual, young and first-time users, and an associated decrease in
presentations to hospital emergency departments.
 Habitual users who were attracted by the legality and easy availability of head shop
products are likely to return to “traditional” illegal substances.
 A proportion of head shops’ customer base will take their business online, where
chat rooms and blogs will keep them updated with new products, perceived effects,
and recommended sources and avenues of delivery.
The study points out that Section 3(2) of the Criminal Justice (Psychoactive
Substances) Act 2010 Act also prohibits the importation of psychoactive substances for
human consumption, including by online means. The authors highlight the importance
of monitoring the impact of policy and legislative change as it is likely that patterns of
drug consumption are likely to change or be displaced. According to the study, the
‘route that this will take remains to be seen but it is likely to be based on factors of
availability and purity and, to a lesser extent, convenience and legality’ (p. 140).
1.3
National action plan, strategy, evaluation and co-ordination
Following a general election in February 2011, a new coalition (Fine Gael and Labour)
government was formed in Ireland. While endorsing the Interim National Drugs
Strategy 2009–2016 (NDS), including the integration of drugs and alcohol strategies,
the new government has also set out its priorities in relation to illicit drugs in its
programme for government. It has assigned responsibility for the NDS to the
Department of Health, which has not had lead responsibility for Ireland’s drugs strategy
since the early 1990s (Pike 2011). The implications of the new priorities and the
reallocation of portfolio responsibility have yet to be fully clarified by the government.
1.3.1
National action plan and/or strategy
Interim National Drugs Strategy 2009–2016 (NDS)
Róisín Shortall TD, Minister of State at the Department of Health with responsibility for
Primary Care, has been given the ‘lead role’ in relation to the NDS. In responses to
questions put to the Minister for Health in Dáil Éireann (Parliament), she confirmed the
new government’s continuing commitment to the strategic objective and aims, and
actions, contained in the NDS, and also to the integration of Ireland’s drug and alcohol
policies:
Our overall strategic objective is to tackle the harm caused to individuals and
society by the misuse of drugs through a concerted focus on supply reduction,
prevention, treatment, rehabilitation and research. The actions set out in the
National Drugs Strategy 2009–2016 facilitate a planned and monitored
approach to achieving the overall strategic aims. The implementation of these
24
actions are being pursued vigorously across a range of Departments and
Agencies in conjunction with the community and voluntary sectors. Progress will
be reviewed on an ongoing basis (Shortall 2011, 31 May-a).
…the alcohol strategy will be included in the national drugs strategy [NDS]. It
was scheduled to happen this year. I have a particular interest in this area and I
want to ensure it is addressed in the NDS. Alcohol abuse is a serious social
problem and alcohol is also a gateway to the abuse of other substances. For
that reason, it will be included in the NDS and I want early progress on that,
particularly in respect of the enforcement of the law on underage drinking. I
hope to report back on that over the coming months (Shortall 2011, 31 May-a).
Programme for government
In March 2011 the new government issued its programme for government for the next
five years, Towards recovery: programme for a National Government 2011–2016 (Fine
Gael and the Labour Party 2011). In this programme, the government brings two new
terms to the fore in relation to social policy – fairness and equality. In their introductory
Statement of Common Purpose, the coalition partners state: ‘We are both committed to
forging a new Ireland that is built on fairness and equal citizenship. ... By the end of
our term in Government Ireland will be recognised as a modern, fair, socially inclusive
and equal society supported by a productive and prosperous economy.’ Along with
chapters on the Economy, Reform and Progress, the programme contains a chapter on
Fairness.
While the authors do not define fairness, the measures in the chapter on Fairness are
placed within the context of principles which, it may be assumed, the government
believes will lead to a fair society – social solidarity, social inclusion, and reduction of
stigma. With regard to equality, the chapter on Fairness does provide some
explanation: under the heading Equality and Social Protection, the authors describe
equality as being at the heart of what it means to be a citizen in Ireland’s democracy:
‘The government believes that everyone has the right to be free from discrimination
and that we all benefit from living in a more equal society’. The government commits to
ensuring equal access to health and to education, and lists measures to ensure
equality and social inclusion for women and men, Travellers, members of the lesbian,
gay, bisexual and transgendered community, workers, members of minority ethnic
groups and immigrants, and people with disabilities.
Although the drugs issue is addressed in the chapter on Fairness, it is not mentioned in
conjunction with either equality or the concepts and principles understood to underpin
fairness. The drugs issue is included in the section entitled Justice and Law Reform,
and four broad objectives are listed:
 to introduce a combined drugs and alcohol strategy (a ‘national addiction
strategy’),
 to provide ‘renewed impetus to the fight against drugs’,
 to ensure that the drugs strategy ‘once again becomes relevant and effective’,
and
 to enhance, where possible, ‘the demand reduction strategies’.
In addition to the four broad objectives, the document lists ‘key priorities for short-term
implementation’, which focus on supply reduction, prevention and rehabilitation; just
one priority relates to harm reduction (see Table 1.3.1.1).
Table 1.3.1.1 Drug-related ‘key priorities’ in Towards recovery: programme for a national
government 2011-2016
Key priorities
For further information, see other
Sections of National Report
Roadside drug testing
1.2.2 and 9.3.1
Prison sentences versus non-custodial alternatives
1.2.2
Mandatory sentencing
1.2.2
Supply reduction and criminal assets seizures
1.2.2
25
Key priorities
Review of the Drug Treatment Court programme
Reduction of flow of drugs into prisons
Customs controls to combat drug supplies at source
Budget transparency and accountability
Rehabilitation services including expansion of places across
country, provision of services at local level, participation
in community employment schemes, and introduction of
compulsory as well as voluntary programmes
Prevention measures including drug awareness programmes in
schools, preventing addiction in schools, and
introducing Education Prevention Units in all task forces
Needle exchange programmes expanded across the country
where needed most
For further information, see other
Sections of National Report
9.4.1
–
–
1.4
5.3.2 and 8.3
–
–
Source: (Fine Gael and the Labour Party 2011), pp. 47, 48 and 49–50
1.3.2
Implementation and evaluation of national action plan and/or strategy
In the previous section, the new Minister of State with responsibility for the NDS,
Róisín Shortall TD, is quoted as saying that progress with regard to implementation of
the NDS will be reviewed on ‘an ongoing basis’. To date, no progress report on the
implementation of the NDS, nor any review of the NDS, has been published.
In February 2011 the Children’s Rights Alliance, a coalition of over 90 nongovernmental organisations (NGOs) working to secure the rights and needs of children
in Ireland, published a review of progress under the national children’s strategy
launched in 2000 (Children's Rights Alliance 2011a). It reported that while there had
been progress in expanding specialist drug treatment for under-18-year-olds, ‘the
impact on children’s lives is unknown as impact of funding on services is unclear’
(p.17).
1.3.3
Other drug policy developments e.g. government declaration, civil society
initiatives
Protecting human rights and combating poverty during the economic downturn
Between 10 and 15 January 2011, at the invitation of the then Irish government, the
United Nation’s independent expert on human rights and extreme poverty, Magdalena
Sepúlveda Carmona, undertook a mission to Ireland. She focused on the impact of the
economic and financial crises in Ireland and the effects of recovery measures on the
level of enjoyment of human rights, in particular economic, social and cultural rights, by
the most vulnerable individuals and groups in Ireland, including problem drug users.
On 17 May 2011 Ms Sepúlveda submitted her report to the UN (Sepúlveda Carmona
2011). In it, she makes concrete recommendations on how to implement a human
rights-based recovery in Ireland.
While acknowledging that the government’s anti-poverty and social inclusion strategies
may need to be adapted in light of the worsening economic situation, she encourages
the government to ensure as a minimum that the 23 high-level goals in the current
social partnership agreement, Towards 2016 (Department of the Taoiseach 2006),
continue to be the primary targets for Ireland’s social policies. She also endorses the
target set by the National Action Plan for Social Inclusion 2007–2016 (NAPincl) (Office
for Social Inclusion 2007) to reduce the number of those experiencing consistent
poverty to between 2% and 4% by 2012, with the aim of eliminating consistent poverty
by 2016. She calls on the government to undertake a human rights review of all
budgetary and recovery policies to ensure they comply with fundamental human rights
principles.
According to Ms Sepúlveda, ensuring non-discrimination and equality are also
fundamental pillars of the human rights framework. Despite the existence of a strong
body of equality legislation in Ireland, Ms Sepúlveda urges the government to be
particularly mindful that policies do not exacerbate the challenges faced by groups
vulnerable to discrimination. She also encourages the government to take positive
26
measures to help these vulnerable segments to ‘regain their equal footing with the rest
of Irish society’. She goes on to observe:
A number of recent measures are concerning in this respect, especially
reductions in child benefits and benefits for job seekers, carers, single parent
families, persons with disabilities and blind persons. The impact of these
measures will be exacerbated by funding reductions for a number of social
services which are essential for the same vulnerable people, including
disability, community and voluntary services, Travellers supports, drug outreach
initiatives, rural development schemes, the Revitalising Areas by Planning,
Investment and Development (RAPID) programme and Youthreach. (para. 34)
In April 2011 the Irish government submitted its National Reform Programme (NRP)
(Government of Ireland 2011) to the European Commission, setting out Ireland’s
headline targets to help achieve the objectives set in Europe 2020 – A European
strategy for smart sustainable and inclusive growth. Under the heading of Poverty, the
Irish government reiterates its commitment, already made in its programme for
government, to the poverty targets set in the NAPincl. The NRP states (p. 24): ‘Taking
the 2008 consistent poverty rate of 4.2% as the baseline year, the numerical
expression of the national poverty target is to lift 186,000 people out of the risk of
poverty and exclusion by 2016. Similarly, the interim target is to lift between 9,000 and
97,000 out of the risk of poverty and exclusion by 2012.’
However, given the country’s current economic difficulties, the government also states
in the NRP that it will review its national poverty targets during 2011. The review will
assess progress made towards the interim target, the likely economic and fiscal
scenario for the years immediately ahead and new data for 2010, which are expected
to give a clearer indication of poverty trends. On the basis of expert opinion about ‘the
statistical feasibility of eliminating consistent poverty and the arguments for adopting
multiple or tiered poverty targets to address the complexity of poverty’, the government
will consider how it can set out ‘different levels of ambition for poverty reduction having
regard to the economic circumstances’.
Press Ombudsman upholds complaint of prejudice against drug users
On behalf of more than thirty Irish drug service providers and professionals, three
voluntary organisations – CityWide Drugs Crisis Campaign (based in Dublin), the Irish
Needle Exchange Forum and the International Harm Reduction Association – lodged a
complaint with the Office of the Press Ombudsman against the national daily
newspaper, the Irish Independent, and an article it published on 18 February 2011 by
columnist Ian O'Doherty entitled ‘Sterilising junkies may seem harsh, but it does make
sense’. The article was reported to comment favourably on a suggestion by a doctor
that such people should be offered money to be sterilised. It described a group of
people whose anti-social activities the writer had witnessed from his taxi as ‘junkies’
and ‘feral, worthless scumbags’, and voiced the writer’s opinion that ‘if every junkie in
this country were to die tomorrow I would cheer’.
On 23 May 2011 the Press Ombudsman issued his decision. He upheld the complaint
that the article breached Principle 8 (Prejudice) of the Code of Practice for Newspapers
and Magazines ‘because it was likely to cause grave offence to or stir up hatred
against individuals or groups addicted to drugs on the basis of their illness’. However,
he had insufficient evidence to make a decision as to whether the description of the
anti-social activities described in the article breached the requirement for truth and
accuracy in reporting:2 ‘because the article’s distinction between an ‘addict’ and a
‘junkie’ is clearly the expression of an opinion, the question of its truth or accuracy
cannot be determined by the Press Ombudsman’ (Office of the Press Ombudsman
2011, 23 May).
2
Principle 1.1 of the Code, under the general heading Truth and Accuracy, states that ‘when a significant inaccuracy,
misleading statement or distorted report or picture has been published, it shall be corrected promptly and with due
prominence’.
27
Exploring community drugs problems including intimidation
In October 2010 CityWide Drugs Crisis Campaign hosted a conference ‘A community
drugs problem: defining the problem – defending the responses’, to provide an
opportunity for those working in local community projects and groups to come together
with local and regional drugs task force community representatives to discuss the key
issues being confronted. The ‘community drugs problem’ was defined by CityWide coordinator, Daithí Doolan, in the following terms: ‘There is no home in Ireland that does
not have a battle with addiction being waged within its four walls. But addiction
becomes a community drugs problem when our very community becomes undermined
by the drug-related problems.’ (Connolly 2011)
Eight months later, in May 2011, CityWide organised a follow-up conference on
intimidation, which had emerged at the conference as a central issue for many
communities throughout Dublin. At its conclusion, CityWide agreed to facilitate the
establishment of an Intimidation Working Group. See Section 9.2.2 for a more detailed
account of this conference and the outcome.
Reviewing treatment models
The National Drugs Conference of Ireland held between 4 and 5 November 2010 in
Dublin and entitled ‘A Continuum of Care within Drug Services’ focused on harm
reduction and abstinence models. Hosted by a group of voluntary sector
organisations,3 the conference sought to highlight the fact that, rather than being
opposing ideologies, these models represent different places along the spectrum of
service provision (Condron and Caprani 2011).
1.3.4
Co-ordination arrangements
On 1 May 2011 all functions relating to the management of the NDS, and the National
Advisory Committee on Drugs (NACD), transferred from the Department of
Community, Equality and Gaeltacht Affairs to the Department of Health.4 Two drugrelated units have been created within the Department of Health, replacing the Office
of the Minister for Drugs (OMD), which was established under the NDS in late 2009 in
the Department of Community, Equality and Gaeltacht Affairs (Shortall 2011, 13 July):
 Drug Policy Unit – to oversee the implementation of the NDS through the five
pillars of supply reduction, prevention, treatment, rehabilitation and research.
 Drugs Programme Unit – to manage the Drugs Initiatives Programmes which are
primarily drug-related projects and initiatives in the drugs task force areas.
The main function of the NACD continues to be to advise the Minister and the
government in relation to the prevalence, prevention, treatment and consequences of
drugs misuse. It also conducts and commissions research in relation to drug misuse.
To date, no explanation has been forthcoming as to whether or how the networking
model promoted in the 2008 OECD review of the Irish public sector, and a distinctive
feature of the organisational structure recommended by the NDS Steering Group for
the OMD, will be retained in the future. See Section 1.3.3 of Ireland’s 2009 National
Report for a full account of how this networking model was to be applied in the OMD
(Alcohol and Drug Research Unit 2009).
On 31 May 2011 Róisín Shortall TD, the Minister for Primary Care, with lead
responsibility for the NDS, responded to questions put to the Minister for Health in Dáil
Éireann (Parliament) with regard to how drug policy would be co-ordinated at
ministerial and departmental level. She and the Minister for Health, Dr James Reilly
TD, will both have roles – the Minister at Cabinet level, the Minister of State at Cabinet
Committee level. While confirming that the Oversight Forum on Drugs (OFD) and the
Drugs Advisory Group (DAG), established under the NDS, will both continue, she went
3
The Irish Needle Exchange Forum (INEF) in conjunction with the Ana Liffey Drug Project, Coolmine Therapeutic
Community and the Irish Association of Alcohol and Addiction Counsellors (IAAAC).
4
The Department of Community, Equality and Gaeltacht Affairs has been abolished. The Office of the Minister for
Children and Youth Affairs, formerly located in the Department of Health and Children, has been established as the
Department of Children.
28
on to talk solely about an ‘oversight committee’, the quarterly meetings of which she
will chair, which indicates that she is referring to the OFD.
The NDS is a cross cutting area of public policy and service delivery and it is
based on a co-ordinated approach across many Departments and agencies in
conjunction with the community and voluntary sectors. The institutional
arrangements to support cross agency working, advise on operational and
policy matters, assess progress across the strategy and address any
operational difficulties include the drugs advisory group and the oversight forum
on drugs. I intend that the work of these bodies will continue, as has been the
case up to now. …
With regard to implementation of the strategy, there is an oversight committee,
which I will chair, and that will continue to meet on a quarterly basis and identify
any logjams, difficulties or delays in implementing the strategy. We are,
therefore, serious about ensuring it is implemented in full. In addition, the
Minister will be responsible for this issue at Cabinet level and it will continue to
have a voice at the Cabinet table. The Cabinet sub-committee on social
exclusion will deal with this issue as well and many of the officials involved in
the oversight will feed into the sub-committee. It will receive attention there and
the sub-committee will meet later this week. I will attend that meeting and I will
be a voice in respect of the NDS. …
The purpose of the oversight committee is to address issues such as crystal
meth and other developments relating to illegal drugs. All the relevant bodies
are represented at a senior level and one of the committee’s functions is to
update all the members on current trends in respect of drug misuse. I give an
assurance that all of the relevant agencies are represented at a senior level. I
will convene the first meeting of the oversight committee in the coming weeks.
(Shortall 2011, 31 May-a).
1.4
Economic analysis
In its programme for government for the next five years, Towards recovery: programme
for a National Government 2011–2016 (Fine Gael and the Labour Party 2011) the new
government, elected in February 2011, included the following statement in the section
entitled ‘Drugs’: ‘We will ensure every government department, agency or task force
responsible for implementing elements of the National Addiction Strategy will be
required to account to the Minister for their budget annually and to demonstrate
progress on achieving targets.’
1.4.1
Public expenditures
The total budgeted public expenditure on the illicit drugs issue in 2010 was €260.296
million. This has been categorised according to Level 1 of the UN’s Categories of
Functions of Government (COFOG) as follows:
Health: $169.442 million
Justice: €60.844 million
Education: €29.549 million
This demonstrates that approximately two-thirds of direct public expenditure on the
illicit drugs issue in 2010 was associated with what are defined as health-related
functions of government. For a detailed breakdown, see Standard Table on Public
Expenditure (STPE).
1.4.2
Budget
See National Report 2010 for most recent information (Irish Focal Point 2010)
29
1.4.3
Social costs
See National Report 2009 for most recent information (Alcohol and Drug Research
Unit 2009)
30
2.
Drug Use in the General Population and Specific targetedGroups
2.1
Introduction
Drug prevalence surveys of the general and school-child population are important
sources of information on patterns of drug use, both demographically and
geographically, and, when repeated, reveal changes over time. In Ireland such surveys
are conducted every three to four years. These surveys increase understanding of
drug use, which, in turn, helps in the formulation and evaluation of drug policies. They
also enable informed international comparisons, provided countries conduct surveys in
a comparable manner. The four main data collection tools in Ireland are described
below.
An All Ireland Drug Prevalence Survey was initiated in 2002 by the National Advisory
Committee on Drugs (NACD) in Ireland and the Public Health Information and
Research Branch (PHIRB), formerly known as the Drug and Alcohol Information and
Research Unit (DAIRU), within the Department of Health, Social Services and Public
Safety (DHSSPS) in Northern Ireland. The main focus of the survey is to obtain
prevalence rates for key illegal drugs, such as cannabis, ecstasy, cocaine and heroin,
on a lifetime (ever used), last year (recent use), and last month (current use) basis.
Similar prevalence questions are also asked of alcohol, tobacco, and other drugs such
as sedatives, tranquillisers and anti-depressants. Attitudinal and demographic
information is also sought from respondents.
The questionnaire and methodology for this drug prevalence survey are based on bestpractice guidelines drawn up by the EMCDDA. The questionnaires are administered
through face-to-face interviews with respondents aged between 15 and 64 normally
resident in households in Ireland and Northern Ireland. Thus, persons outside these
age ranges, or who do not normally reside in private households, have not been
included in the survey. This approach is commonly used throughout the EU and
because of the exclusion of those living in institutions (for example, prisons, hostels)
this type of prevalence survey is usually known as a general population survey.
The first iteration of this general population drug prevalence survey was undertaken in
2002/3 (National Advisory Committee on Drugs and Drug and Alcohol Information and
Research Unit 2005b), and a second iteration in 2006/7 (National Advisory Committee
on Drugs and Drug and Alcohol Information and Research Unit 2008). A series of
bulletins reporting the findings of the 2002/3 and 2006/7 iterations have been published
and can be found at http://www.nacd.ie/publications/index.html
The most recent (third) survey was conducted in 2010/11.
As with other European surveys, people over the age of 64 are excluded from this
survey, as they grew up in an era when both the use and availability of illegal drugs
were very limited. Therefore, surveys with older people have, to date, shown very low
rates of use even on a lifetime basis. This situation will change over time as the
younger population grows older: lifetime prevalence rates are likely to increase for a
considerable period of time. When examining the data and comparing results over
time, last-year use is the best reflection of changes as it refers to recent use. Lastmonth use is valuable insofar as it refers to current use.
The Survey of Lifestyles, Attitudes and Nutrition (SLÁN) is a national survey of the
lifestyles, attitudes and nutrition of people living in Ireland. To date, three surveys have
been completed – in 1998 (Friel, et al. 1999), 2002 (Kelleher, Cecily, et al. 2003) and
2007 (Morgan, et al. 2008) – and have examined the health and social status, and
related health service use, of adults aged 18 years and older living in private
households. SLÁN 1998 and SLÁN 2002 were postal surveys, based on samples from
the electoral register, and involved 6,539 respondents in 1998 (62% response rate) and
5,992 in 2002 (53% response rate). SLÁN 2007 interviewed 10,364 respondents face31
to-face in their homes, based on samples from the GeoDirectory (62% response rate).
The SLÁN data are not comparable with the results of the 2002/3, 2006/7 and 2010/11
all-Ireland general population drug prevalence survey as the SLÁN survey excludes
those aged between 15 and 17 years and includes those aged over 65 years.
The Health Behaviour in School-aged Children (HBSC) is a cross-national research
study conducted in collaboration with the WHO (World Health Organization) Regional
Office for Europe. The study aims to gain insights into, and increase our understanding
of, young people's health and well-being, health behaviours and their social context.
HBSC was initiated in 1982 and is conducted every 4 years. It is a school-based survey
with data collected through self-completion questionnaires administered by teachers in
the classroom.
The Health Promotion Research Centre, National University of Ireland, Galway was
invited to join the HBSC network in 1994 and conducted the first survey of Irish
schoolchildren in 1998 (Friel, et al. 1999); the survey has been repeated in Ireland in
2002 (Kelleher, Cecily, et al. 2003) and 2006 (Nic Gabhainn, S, et al. 2007).
The European School Survey Project on Alcohol and Other Drugs (ESPAD) is a
collaborative effort of independent research teams in about 40 European countries.
Data on alcohol and illicit drug use among 15–16-year-olds have been collected every
four years since 1995, using a standardised method and a common questionnaire. The
Swedish Council for Information on Alcohol and Other Drugs (CAN) initiated the project
in 1993. Support has been provided by the Pompidou Group at the Council of Europe,
the Swedish Ministry of Health and Social Affairs, the Swedish National Institute of
Public Health and the European Monitoring Centre for Drugs and Drug Addiction
(EMCDDA). The data collections in the individual countries are funded by national
sources. The rationale for the survey is that school students are easily accessible and
are at an age when onset of substance use is likely to occur. (By definition, early
school leavers, a group known to be vulnerable to alcohol and drug use, are not
represented.)
The fourth iteration of the survey was conducted in 35 European countries, including
Ireland, in the spring of 2007 and the results were published in March 2009 (Hibell, et
al. 2009). The fourth survey collected information on alcohol and illicit drug use among
15–16-year-olds; 2,249 students from 94 randomly-selected schools participated,
which represents a response rate of 78%. Fewer schools and students participated in
2007 than in 2003. The Irish data showed a marked decrease in lifetime use of any
illicit drug between 2003 (40%) and 2007 (22%). As the majority of those who had tried
any illicit drug had used cannabis (marijuana or hashish), the decrease in illicit drug
use was influenced by the considerable decrease in the number of students who had
tried cannabis at some point in their lives, from 39% in 2003 to 20% in 2007 (European
average 19%). Data were collected for the fifth iteration of ESPAD in spring 2011 and
the survey findings will be published in 2012.
2.2
Drug use in the general population (based on probabilistic sample)
On 22 November 2011, the National Advisory Committee on Drugs (NACD) and and
the Public Health Information and Research Branch (PHIRB) within the Department of
Health, Social Services and Public Safety (DHSSPS) in Northern Ireland published
jointly the results of the third all-Ireland general population drug prevalence survey.
The Irish survey followed best practice guidelines recommended by the EMCDDA. The
questionnaire, based on the ‘European Model Questionnaire’, was administered in
face-to-face interviews with respondents aged between 15 and 64 years normally
resident in households in Ireland and Northern Ireland. The questionnaire in the
2010/11 general population survey was revised to include better measures of alcohol
from the European Comparative Survey on Alcohol and the SMART project. The
questionnaire also included two measures of cannabis dependency – the MCIDI based
32
on clinical diagnosis and the SDS used in a number of studies on treatment. Three
questions were asked about new psychoactive substances sold in headshops or
online. The response options to the other opiate-type substances were increased to
include codeine and other commonly used opiates. Some of the questions from the
perceptions and risks module were removed to make time and space for the new
questions. With the exception of these questions and their corresponding showcards,
the questionnaire employed for the 2010/11 survey was the same as that used in
2006/7. Fieldwork was carried out by MORI MRC during late 2010 and early 2011. The
final achieved sample was 5,134 in Ireland. This represented a response rate of 60%.
The sample was weighted by gender, age and region to ensure that it was
representative of the general population. The main measures of use were lifetime (ever
used), use in the last year (recent use) and use in the last month (current use). The
detailed methodological background to the general population survey on drug use and
the results are presented in Standard Table 1.
The proportion of adults (aged 15–64 years) who reported using an illegal drug in their
lifetime (ever used) increased by just over 3%, from 24% in 2006/7 to 27.2% in
2010/11 (Table 2.2.1). The proportion of young adults (aged 15–34 years) who
reported using an illegal drug in their lifetime also increased by just over 4%, from
31.4% in 2006/7 to 35.7% in 2010/11. As expected, more men (35.5%) reported using
an illegal drug in their lifetime than women (19%).
The proportion of adults who reported using an illegal drug in the last year (recent use)
remained stable at 7.2% in 2006/7 and 7% in 2010/11 (Table 2.2.1). The proportion of
young adults who reported using an illegal drug in the last year also remained stable at
12.1% in 2006/7 to 12.3% in 2010/11. The proportion of young adults who reported
using an illegal drug in the last month (current use) was 5.3%.
Table 2.2.1 Lifetime, last-year and last-month prevalence of illegal drug use in Ireland, 2002/3,
2006/7 and 2010/11
Illegal
Adults
Males
Females
Young adults
drug
15–64 years%
15–64 years
15–64 years
15–34 years
use*
%
%
%
2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7 2010/11
Lifetime 18.5
24.0
27.2
24.0
29.4
35.5
13.1
18.5
19.0
26.0
31.4
35.7
Last
5.6
7.2
7.0
7.8
9.6
10.4
3.4
4.7
3.6
9.7
12.1
12.3
year
Last
3.0
2.9
3.2
4.1
4.3
5.3
1.7
1.4
1.1
5.2
4.8
5.3
month
* Illegal drugs in this context are amphetamines, cannabis, cocaine powder, crack, ecstasy, heroin, LSD, magic mushrooms, poppers
and solvents.
Source: (National Advisory Committee on Drugs and Drug and Alcohol Information and Research Unit 2005b) (National Advisory
Committee on Drugs and Drug and Alcohol Information and Research Unit 2008) and unpublished data for 2010/11 from NACD
Lifetime cannabis use increased over the four years since the previous survey in
2006/7 but last year use remained stable (Table 2.2.2). The proportion of adults who
reported using cannabis at some point in their life increased from 21.9% in 2006/7 to
25.3% in 2010/11. The proportion of young adults who reported using cannabis in their
lifetime also increased, from 28.6% in 2006/7 to 33.4% in 2010/11.
The proportion of adults who reported using cannabis in the last year remained stable
at 6.3% in 2006/7 and 6.0% in 2010/11. The proportion of young adults who reported
using cannabis in the last year remained stable at 10.4% in 2006/7 to 10.3% in
2010/11. The proportion of adults who reported using cannabis in the last month
remained stable at 2.8%.
The lifetime prevalence rate was higher for men (33.2%) than for women (16.6%).
Table 2.2.2 Lifetime, last-year and last-month prevalence of cannabis use in Ireland, 2002/3, 2006/7
and 2010/11
Cannabis Adults
Males
Females
Young adults
use
15–64 years
15–64 years
15–64 years
15–34 years
%
%
%
%
2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7
33
2010/11
Cannabis Adults
use
15–64 years
%
Lifetime
17.4
21.9
Last year
5.0
6.3
Last month 2.6
2.6
25.3
6.0
2.8
Males
15–64 years
%
22.4
27.0
7.2
8.5
3.4
4.0
33.2
9.1
4.7
Females
15–64 years
%
12.3
16.6
2.9
3.9
1.7
1.1
17.5
2.9
0.9
Young adults
15–34 years
%
24.0
28.6
8.6
10.4
4.3
4.2
33.4
10.3
4.5
Source: (National Advisory Committee on Drugs and Drug and Alcohol Information and Research Unit 2005a) (National Advisory
Committee on Drugs and Drug and Public Health Information and Research Branch 2008) and unpublished data 2010/11 from NACD.
Lifetime cocaine use increased in 2010/11 compared to 2006/7 but last-year use
remained stable. The proportion of adults who reported using cocaine (including crack)
at some point in their lives increased from 5.3% in 2006/7 to 6.8% in 2010/11 (Table
2.2.3). The proportion of young adults who reported using cocaine in their lifetime also
increased, from 8.2% in 2006/7 to 9.4% in 2010/11. As expected, more men (9.9%)
reported using cocaine in their lifetime than women (3.8%).
The proportion of adults who reported using cocaine in the last year remained stable at
1.7% in 2006/7 and 1.5% in 2010/11 (Table 2.2.3). The proportion of young adults who
reported using cocaine in the last year decreased marginally from 3.1% in 2006/7 to
2.8% in 2010/11.
The proportion of adults who reported using cocaine in the last month remained stable
at 0.5%.
Table 2.2.3 Lifetime, last-year and last-month prevalence of cocaine use (including crack) in
Ireland, 2002/3, 2006/7 and 2010/11
Cocaine
Adults
Males
Females
Young adults
use
15–64 years
15–64 years
15–64 years
15–34 years
%
%
%
%
2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7 2010/11
Lifetime
3.0
5.3
6.8
4.3
7.0
9.9
1.6
3.5
3.8
4.7
8.2
9.4
Last
1.1
1.7
1.5
1.7
2.3
2.3
0.5
1.0
0.7
2.0
3.1
2.8
year
Last
0.3
0.5
0.5
0.7
0.8
0.8
0.0
0.2
0.3
0.7
1.0
1.0
month
Source: (National Advisory Committee on Drugs and Drug and Alcohol Information and Research Unit 2006) (National Advisory
Committee on Drugs and Public Health Information and Research Branch 2008) and unpublished data 2010/11 from NACD.
Almost 11% of young adults claimed to have tried ecstasy at least once in their lifetime
in 2010/11 (Table 2.2.4).
Table 2.2.4 Lifetime, last-year and last-month prevalence of ecstasy use in Ireland, 2002/3, 2006/7
and 2010/11
Ecstasy
Adults
Males
Females
Young adults
use
15–64 years
15–64 years
15–64 years
15–34 years
%
%
%
%
2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7 2010/11 2002/3 2006/7 2010/11
Lifetime
3.7
5.4
6.9
4.9
7.2
10.1
2.6
3.6
3.7
7.1
9.0
10.9
Last
1.1
1.2
0.5
1.7
1.8
0.6
0.5
0.6
0.3
2.0
2.4
0.9
year
Last
0.3
0.3
0.1
0.7
0.5
0.1
0.0
0.2
0.0
0.6
0.6
0.1
month
Source: (National Advisory Committee on Drugs and Drug and Alcohol Information and Research Unit 2005b) (National Advisory
Committee on Drugs and Drug and Alcohol Information and Research Unit 2008) and unpublished data 2010/11 from NACD.
The considerable increase in the proportions using any illegal drug at some point in
their lives was influenced by the facts that drug use in Ireland is a recent phenomenon
and that the population of lifetime and recent drug users in Ireland is relatively young.
Drug use is measured among adults aged 15–64, and those leaving this age group
over the next ten years are less likely to have been exposed to drug use than those
entering the measurement cohort.
34
2.3
Drug use in the school and youth population (based on
probabilistic sample)
Drug use among early school leavers compared with school attendees
Haase and Pratschke estimated drug use among 479 early school leavers and 512
school attendees, aged 16–18 years, and identified risk and protective factors for
substance use (Haase and Pratschke 2010). Data were collected throughout Ireland
between March and May and again between September and December 2008. The
participants were interviewed face-to-face and their answers were recorded using
computer-assisted personal interviewing devices. The proportions using each drug are
presented in Table 2.3.2. It is clear that substance use is more common (with the
exception of alcohol) among early school leavers than among school attendees.
Table 2.3.2 Proportion of early school leavers (479) and school attendees (512) using different
substances, 2008
Lifetime
Year prior to the survey
Month prior to the survey
Early
School
Early school
School
Early
School
school
attendees*
leavers
attendees*
school
attendees*
leavers
leavers
%
%
%
%
%
%
Tobacco
81.6
53.3
73.7
38.3
68.9
27.1
Alcohol
89.6
85.7
84.3
78.1
65.3
54.4
Cannabis
57.0
24.2
43.0
14.5
33.6
7.6
Cocaine
25.9
3.7
14.8
2.5
5.4
0.2
Crack
1.3
1.2
0.4
1.0
0.0
0.0
Amphetamines
18.4
3.1
5.6
1.0
0.8
0.0
LSD
5.6
2.0
2.3
2.0
0.0
0.0
Magic mushrooms
12.1
2.5
5.4
0.4
0.4
0.0
Heroin
1.3
0.0
0.4
0.0
0.0
0.0
Tranquillisers
3.8
1.2
1.9
0.2
0.8
0.0
‘Legal’ party pills
23.4
6.8
13.2
3.9
2.9
0.2
Anti-depressants
8.4
2.0
5.4
0.4
2.1
0.4
Ecstasy
27.3
4.9
17.5
2.3
7.1
0.4
Solvents
14.4
5.5
2.9
0.4
0.8
0.0
Anabolic steroids
0.8
0.02
0.2
0.2
0.2
0.0
*Proportions for school attendees are adjusted by age and gender to match the composition of early school leavers.
Source: (Haase and Pratschke 2010)
Gateway drug transitions in rural Irish school children
Van Hout (Van Hout, Marie Claire and Ryan 2011) presented the findings from a largescale mixed-method study on substance use among youth in the rural south-east of
Ireland. The findings were discussed with reference to the design of culturally
appropriate and drug specific education initiatives in rural Ireland. The survey
instrument contained questions on demographics, alcohol use, cigarette use, drug
initiation, and drug use. A random sample of 345 school children (aged 14 to 17 years)
was selected from five participating schools in a rural area in the south-east of Ireland;
91% of the selected school children participated in the study. The participating schools
represented private, single sex public, and mixed public schools in the area. Standard
ethical and consent procedures were followed. The structured nature of the school
setting facilitated the administration of the research. The researcher emphasised the
anonymity of the survey prior to administering it to the selected children and remained
in each school in order to collect the completed questionnaires. The researcher did not
present the findings by school type as some schools might have been identifiable. The
research findings were presented thematically.
Self-reported cigarette use
Of the sample, 45% reported smoking cigarettes at least once in their life, of whom
34% smoked cigarettes on a daily basis, 26% smoked less than daily or infrequently,
and 31% tried smoking only once. The proportion of girls and boys who reported
smoking was similar. The survey identified a significant association between cigarette
smoking and alcohol use, with 100% of those reporting lifetime prevalence of cigarette
use having drunk alcohol (p<0.001), a large proportion of those who reporting
‘drunkenness’ having smoked cigarettes ( p<0.05), and 100% of those reporting drug
35
use having smoked cigarettes (p<0.02). These findings support the claim that cigarette
smoking is a gateway to alcohol and drug use.
Self-reported alcohol use
In terms of self-reported alcohol use, 62% of the respondents reported alcohol use
during their lifetime, with no significant differences between boys and girls, and 36%
reported drunkenness. The concurrent qualitative element of this study highlighted the
frequency and regularity of alcohol consumption within religious and family gatherings
in Irish society. Many young people reported drinking alcohol at home in the presence
of their parents and/or with parental permission. In addition, the survey identified
significant associations between lifetime alcohol and drug prevalence (p<0.001), and
between drunkenness and lifetime drug prevalence (p<0.0001). This highlights the
potential mediating role that alcohol plays in providing opportunities to commence
other drug use.
Self-reported other drug use
Lifetime prevalence of drug use was reported by 24% of the sample, with similar
proportions of girls and boys reporting drug use. There was a significant association
between lifetime prevalence of cannabis use and alcohol use (p<0.0001), lifetime
prevalence of cannabis use and drunkenness (p<0.0001), and frequency of cannabis
and alcohol use (p<0.0001). This was supported in the qualitative phase of the
research, where young people described their first introduction to cannabis and
subsequent use when drinking alcohol or under its influence. Interestingly, given that
both tobacco and cannabis were smoked, the survey did not identify an association
between lifetime use of cannabis and cigarettes. However, the qualitative research did
observe similar risk perceptions where the participants perceived the smoking of
cannabis as similar to tobacco in relation to safety, can be consumed in a short time
period, and avoidance of legal repercussions.
No student reported use of cocaine or heroin, for two reasons – fear of the
consequences of more serious drug use and availability of cannabis. The increasing
availability of cannabis and the emerging social acceptance of cannabis use among
young people in the south-east is cause for concern, particularly in light of the
increasing gravitation to hard drugs (such as cocaine and heroin) across the whole of
Ireland.
No significant relationships between tobacco or alcohol use and the use of specific
drugs such as ecstasy, amphetamine, cocaine, solvents, heroin, ketamine,
tranquilisers, and magic mushrooms were detected but this may be explained by the
small numbers who reported using these drugs.
2.4
Drug use among targeted groups/settings at national and local level
(university students and conscript surveys, migrants, music venues gay
clubs, gyms)
Substance use among university students in Cork
Cahill and Byrne (Cahill and Byrne 2010) examined alcohol and other drug use among
students attending a student health centre. Students aged 18 and over, attending
University College Cork’s Student Health Department over a two-day period in
November 2008, were invited to complete an anonymous questionnaire on their alcohol
and other drugs use. The questionnaire was based on the one used in the College
Lifestyle and Attitudinal National (CLAN) Survey (Hope, et al. 2005). The response rate
was 91% with 181 of 198 questionnaires completed. Over half (53%) of the
participants were between 18 and 21 years old, and 76% were female, mirroring the
3:1 ratio of female to male attendance at the student health centre. The results of this
survey represent alcohol and other drug use among attendees at third-level student
health services rather than alcohol and other drug use among the student population
attending the university.
36
Cannabis was the most common illegal drug reportedly used by respondents: 49% had
used cannabis at some point in their lives, 27% in the year prior to the survey, and 13%
in the 30 days prior to the survey. Of those who used cannabis in the year prior to the
survey, 44% used it on more than 10 occasions. Cannabis use was more common
among male students.
Cocaine was the second most common illegal drug used by respondents, with 7%
reportedly using it in the year prior to the survey, and ecstasy was the third most
common illegal drug used, with 4% reportedly using it in the year prior to the survey.
Only female students reported ecstasy use. Other drugs used included magic
mushrooms, tranquillisers or sedatives, amphetamines and LSD. No respondent
reported that they had ever used heroin, drugs by injection, or crystal meth.
Almost all students attending the student health centre (98%) had consumed alcohol at
some point in their life and students began drinking at an average age of 15.9 years
(range 1– 30 years). Seventy-six per cent consumed an alcoholic drink in the week
prior to the survey. Women’s preferred alcoholic drink was spirits (96%), followed by
beer/cider (77%) and then wine (75%). Men preferred beer/cider (96%), followed
closely by spirits (93%) and then wine (73%). Binge drinking, which was defined as
‘drinking at least four pints of beer/cider, or a bottle of wine, or its equivalent on a single
drinking occasion’, was a frequent occurrence, with 83% of respondents reporting
binge drinking in the year prior to the survey. A significant proportion (45%) reported
binge drinking once a week or more. All student respondents who drank reported
suffering at least one adverse consequence as a result of their own drinking. The most
common adverse consequences reported were regretting something said or done,
feeling adverse effects whilst at college, missing days from college, or harm to college
studies or work. Nearly 1 in 4 male drinkers had been in a fight as a result of their
drinking and approximately 1 in 10 reported unintentional or unprotected sex as a result
of alcohol. The majority of respondents (63%) reported suffering adverse
consequences of someone else’s drinking.
The authors did not compare the findings with the CLAN survey as this current study
was conducted among a sub-sample of students who were attending a health service
rather than among the general population of students.
Substance use among students in Limerick
Houghton and colleagues (2011) (Houghton, et al. 2011) examined students’ health and
lifestyles in a quota sample survey; the survey included questions on recent drug use (last
year). One thousand students attending lectures were asked to participate in the survey and
76% (742) did so. The participants ranged in age from 17 to 63 years, and half were aged 20 or
younger; 52% (386) were men. Five (0.7%) participants reported that they had taken ‘Revelin’
(the name of a dummy drug) and these were excluded from the analysis. The most common
illegal drug taken was cannabis, with one third of students reporting taking it at least once in the
year prior to the survey (Table 2.4.1). Cocaine was also a popular drug with 13% taking it during
the same time period. Ecstasy was taken by 12% of respondents. Similar proportions took
magic mushrooms (7%) and amphetamines (7%). Five per cent were prescribed tranquillisers
and 3% took tranquillisers that were not prescribed for them. Similar proportions took LSD and
solvents. Only 0.9% had taken heroin in the last year and 0.5% had injected an illicit drug in the
last year. Almost 18% of respondents took more than one drug concurrently (polydrug use).
Men were marginally more likely to take drugs than women. The authors stated that the high
rates of drug use have implications for physical and mental health.
37
Table 2.4.1 Drug use and frequency in the last year for third-level students, Limerick
All
Male
Drug Type
Never
Once or
3 or
Never
Once
3 or
Twice
More
or
More
Twice
Cannabis
66.8%
11.2%
22.1%
67.9%
9.9%
22.2%
(412)
(69)
(136)
(226)
(33)
(74)
Cocaine
87.0%
(562)
7.3%
(47)
5.7%
(37)
87.1%
(311)
5.6%
(20)
7.3%
(26)
87.0%
(240)
Female
Once
3 or
or
More
Twice
13.0
21.5
%
%
(35)
(58)
9.8%
3.3%
(27)
(9)
Ecstasy
87.6%
(567)
92.9%
(598)
93.0%
(599)
94.9%
(610)
96.9%
(622)
6.3%
(41)
5.1%
(33)
4.2%
(27)
3.6%
(23)
2.3%
(15)
6.0%
(39)
2.0%
(13)
2.8%
(18)
1.4% (9)
85.7%
(306)
91.9%
(327)
91.6%
(327)
95.2%
(338)
96.6%
(344)
7.3%
(26)
5.6%
(20)
5.0%
(18)
3.7%
(13)
2.2%
(8)
7.0%
(25)
2.5%
(9)
3.4%
(12)
1.1%
(4)
1.1%
(4)
90.3%
(250)
94.2%
(268)
94.9%
(261)
94.5%
(260)
97.4%
(267)
5.4%
(15)
4.7%
(13)
3.3%
(9)
3.6%
(10)
2.2%
(6)
4.3%
(12)
1.1%
(3)
1.8%
(5)
1.5%
(4)
0.4%
(1)
96.3%
(620)
96.3%
(619)
99.1%
(638)
99.5%
(642)
2.0%
(13)
2.5%
(16)
0.6% (4)
1.7%
(11)
1.1% (7)
0.3% (2)
0.2% (1)
95.5%
(341)
95.5%
(340)
98.6%
(352)
99.4%
(355)
2.5%
(9)
2.8%
(10)
1.1%
(4)
0.3%
(1)
2.0%
(7)
1.4%
(5)
0.3%
(1)
0.3%
(1)
97.5%
(268)
97.1%
(268)
99.6%
(274)
99.6%
(275)
1.5%
(4)
2.2%
(6)
0.4%
(1)
0.4%
(1)
1.1%
(3)
0.7%
(2)
0%
(0)
0%
(0)
Magic
Mushrooms
Amphetamine
Tranquillisers
with prescription
Tranquillisers
without
prescription
LSD
Solvents
Heroin
Drugs by
injection
0.8% (5)
0.3% (2)
Never
65.6%
(177)
Source: (Houghton, et al. 2011)
38
3.
Prevention
3.1
Introduction
Drug prevention is one of the four pillars in the National Drugs Strategy (interim)
2009–2016 (Department of Community Rural and Gaeltacht Affairs 2009). The
Strategy states that ‘a tiered or graduated approach to prevention and education
measures in relation to drugs and alcohol should be developed with a view to providing
a framework for the future design and development of interventions’ (para. 3.56).
It identifies three levels in this framework:
 Universal (primary) prevention programmes, aimed at the general population such
as students in schools, to promote overall health of the population and to prevent
the onset of drug and alcohol misuse. Measures often associated with this type of
programme include awareness campaigns, school drug/alcohol education
programmes and multi-component community initiatives.
 Selected (secondary) prevention programmes, aimed at groups at risk, as well as
subsets of the general population including children of drug users, early school
leavers and those involved in anti-social behaviour, to reduce the effect of risk
factors present in these subgroups by building on strengths and developing
resilience and protective factors.
 Targeted (tertiary) prevention programmes, for people who have already started
using drugs/alcohol, or who are likely/vulnerable to engage in problematic
drug/alcohol use (but may not necessarily be drug/alcohol dependent), or to
prevent relapse. These programmes are aimed at individuals or small groups and
address specific needs.
This framework combines universal, selected and targeted with the old classificatory
framework of primary, secondary and tertiary, which is misleading in that it implies that
universal prevention is also the primary step in prevention. In Ireland young people and
their families are the main target groups for drug prevention activities, which consist
mainly of universal and selected prevention, with little focus on targeted prevention.
The NDS identifies as priorities for Prevention, improving the delivery of SPHE in
primary and post-primary schools and co-ordinating the activities and funding of youth
interventions in out-of-school settings to optimise their impacts. Drug prevention
interventions in schools are delivered through the Walk Tall (primary schools) and the
Social, Personal and Health Education (SPHE) (post-primary schools) programmes.
The SPHE programme aims to improve social and personal competencies in students
so they can understand and counter the many social influences that are seen as
contributing to their use of drugs and alcohol. In the community, prevention
programmes are provided in different settings, such as youth clubs and youth cafés,
and by means of diversion activities provided by the statutory, voluntary and
community sectors.
The National Drugs Strategy calls for a continued focus on orienting educational and
youth services towards early interventions for people and communities most at risk.
Actions are to be developed to further support the families of drugs users, and
community development is acknowledged as an important step in building the capacity
of local communities to avoid, or respond to and cope with, drug problems. Early
school leavers are targeted through measures such as the School Completion
Programme and embedding the government’s DEIS (Delivering Equality of Opportunity
in Schools) Action Plan, which tackles disadvantage among the school-going
population, in schools in LDTF areas. The Department of Education and Science (DES)
has also developed a strategy to tackle educational disadvantage and early school
leaving in the Traveller community.
Stand-alone mass media awareness and information campaigns are regarded as less
effective than multi-component, multi-level interventions that reflect the complex nature
of drug prevention and harm reduction. The NDS proposes that preference be given to
39
the development of timely awareness campaigns targeted in a way that takes individual
social and environmental conditions into account key areas such as third-level
institutions, workplaces, sports and other community and voluntary organisations.
3.2
Universal prevention
3.2.1
School
The Social, Personal and Health Education (SPHE) programme is the main vehicle
through which substance use prevention is delivered in both primary and post-primary
schools. The SPHE programme is a mandatory part of the primary school and postprimary (junior cycle) curriculum and supports the personal development, health and
well-being of students through ten modules including a module on substance use. The
themes and content of modules are based around helping students to understand the
nature of social influences that impact on their development and decision-making, and
helping them to develop adequate life-skills to improve their self-esteem, develop
resilience and build meaningful and trusting relationships.
Actions 20 and 21 in the NDS are the policy mechanisms supporting implementation of
SPHE as the main universal prevention programme in schools. Table 3.2.1.1 gives an
update on progress against these actions.
Table 3.2.1.1: Progress on actions in NDS to deliver universal prevention measures in primary and
post-primary schools, March 2011
Actions
Action
20
Action
21
Improve the delivery of SPHE in primary and
post-primary schools through:
•
the implementation of the
recommendations of the SPHE
evaluation in post-primary schools; and
•
the development of a whole school
approach to substance use education in
the context of SPHE
Ensure that substance use policies are in
place in all schools and are implemented.
Progress to date on implementation
Nic Gabhainn et al. 2008 made 41 recommendations
to improve the implementation of SPHE in post-primary schools
(Nic Gabhainn, Saoirse, et al. 2008).
The implementation of these recommendations is ongoing.
(Department of Community Equality and Gaeltacht Affairs 2011
23 March)
The results from a survey of schools undertaken by
the Department of Education and Skills in 2009 indicates that:

84% of primary schools in local drug task force areas
had a substance abuse policy;

96% of post-primary schools in local drug task force
areas had a substance abuse policy.
(Department of Community Equality and Gaeltacht Affairs 2011
23 March)
Monitor the effectiveness of the
implementation of substance use policies in
schools through the whole-school evaluation
process and the inspectorate system and
ensure that best practice is disseminated to
all schools.
Most post-primary schools had policies to address substance
use.
(Department of Education and Science Evaluation Support and
Research Unit, 2009 #1891
In 2010 the number of whole-school evaluations (which include
the area of SPHE) completed were 231 at primary level and 39 at
post-primary level.
The implementation of SPHE in primary schools
An evaluation of the implementation of SPHE in 40 primary schools was published in
2009 (Department of Education and Science Evaluation Support and Research Unit
2009).The evaluation, undertaken in 2007, focuses on the teaching and learning in
SPHE and on the quality of pupils’ achievement. Table 3.2.1.2 provides details on the
methods used to undertake the evaluation.
Table 3.2.1.2: Methods used to evaluate SPHE in primary schools in 2007
Methods of data collection
Class settings observed
Interviews with boards of management
Number
173
40
40
Methods of data collection
Interviews with principals
Focus groups with teachers
Focus groups with pupils
Focus groups with post holders that had responsibility for SPHErelated duties
Questionnaires completed by senior pupils
Questionnaires completed by parents
Number
40
40
40
19
1013
902
Source: (Department of Education and Science Evaluation Support and Research Unit 2009)
In reporting on the findings of the evaluation, the authors used the following
conventions:
 Almost all = more than 90%
 Most = 75%–90%
 Majority = 50%–74%
 Fewer than half = 25%–49%
 A small number = 16%–24%
 A few = up to 15%
Quality of learning
Observations revealed that in most classrooms, pupils actively engaged in team and
partner-based activities and games. In one in eight of the classrooms observed,
teachers underused active-learning approaches and overused didactic teaching
methods which restricted the involvement of pupils in active learning.
In most classrooms observed, learning activities were interesting and challenging. In
one in six classrooms, learning activities were uninteresting and less challenging as
teachers did not match the content of materials to the abilities and interest of pupils.
In most classrooms observed, SPHE was taught on a regular basis and there was clear
evidence of regular progress in the pupils’ learning. There was scope for development
in the progress of pupils’ learning in one in five of the classrooms observed mainly due
to the sporadic delivery of SPHE.
All pupils who participated in the focus groups expressed the view that learning in
SPHE was important and could relate what they were learning to their current and
future real-life experience. They had a good understanding of the content of SPHE and
the associated values, attitudes and skills. In particular, they were able to reflect on
issues relating to substance misuse and showed a good understanding of such issues.
Providing opportunities for pupils to work actively with their peers on interesting issues
was an important feature of SPHE. Most pupils responding to the questionnaire had
regular opportunities to work in groups, but 18% did not report such opportunities. Most
pupils agreed with the statement ‘preferred to articulate their opinions in class’ but
fewer than half believed their peers were willing to listen to them. Pupils’ learning was
evident on a number of topics including happiness, friendship, responsibility, healthy
eating and exercise, safety and protection, and care of the environment. Pupils’
learning on topics such as talking about personal feelings and asking questions about
their body and how it changes was less evident.
Almost all pupils said they would know what to do if they were bullied at school and
three quarters of students said the school adequately dealt with bullying.
Quality of teaching
In most of the SPHE lessons observed, teachers used a variety of active-learning
approaches, with one-third displaying best practice. Predominant active–learning
approaches included talk, discussion and written activities. In most class settings
observed, talk and discussion were focused around the concepts of SPHE and clear
learning objectives were included and problem-solving techniques encouraged. In
fewer than half of lessons observed, drama and co-operative games were used and in
a small number of lessons observed, ICT, media studies, and pictures and
41
photographs were used. In 12% of classrooms observed there was room for
improvement with the range of active-learning approaches used and the manner of
their use.
In a majority of classrooms observed, learning opportunities in groups, including circletime activities and co-operative games, was a regular feature. Inspectors praised
teachers for encouraging teamwork and partnership among pupils. In almost one
quarter of classrooms observed, opportunities to learn through group-based activities
were much less than desired. Observation showed that most teachers provided pupils
with opportunities to acquire values, attitudes and skills through active learning. Almost
all teachers observed regularly used real-life events from school, play and the
community in their teaching in SPHE, with almost half displaying best practice.
Teachers reported that the Walk Tall module, a specific substance misuse prevention
programme, was among the resources they used most regularly when delivering the
SPHE curriculum in the classroom.
Parents’ views on SPHE
Most parents replying to the questionnaire confirmed their awareness of SPHE plans in
their child’s school and 18% were either unaware of or unsure of the school’s SPHE
plan. Some parents submitted open-ended comments in addition to the questionnaire
and praised the effective manner in which SPHE was addressed and the efforts made
by staff to keep parents informed. Some parents said it was the duty of the school to
keep them informed about plans for SPHE while others said it was their duty to inform
themselves.
Just over half the schools reported having allocated specific responsibility for the coordination of SPHE to a designated teacher with special duties.
Most parents responding to the questionnaire were familiar with the work their child did
in SPHE on personal safety and co-operating with others. Almost all parents were
familiar and supportive of their children’s work in SPHE on healthy eating and exercise.
There was scope for encouraging the involvement of parents when planning the
implementation of SPHE in more than half the schools evaluated.
The views of principals on SPHE
Almost 60% of principals interviewed said schools engaged a variety of external
speakers and agencies to support the implementation of the SPHE curriculum. Almost
two-thirds said they had organised in-school or external SPHE training for their staff, or
both, within the last five years. Training in matters relating to substance use featured
prominently.
Assessment of SPHE
In the majority of classrooms observed, there was room for improvement in the range
of assessment strategies used by teachers to assess the progress of pupils, to inform
teaching and learning and update parents. Assessment strategies tended to rely on
unrecorded teacher observations and some examples of pupils’ work in copybooks and
worksheets. Slightly over a quarter of pupils responding to the questionnaire believed
their teacher thought they were making progress at SPHE and 70% did not know what
their teacher thought about their progress in SPHE. Very good assessment practices
were found in only 15% of classrooms observed. Only 5% of schools sought pupils’
views when planning the implementation of SPHE.
3.2.2
Family
The Family Support Network (FSN) is an autonomous self-help organisation that
advocates for and works with families affected by drug use and addiction. The FSN
designs and delivers innovative initiatives to raise awareness of the issue of drug
addiction in families and to respond to the needs of families affected by drug addiction.
It is particularly active in seeking to engage ‘hard-to-reach’ families, including families
42
in migrant and/or ethnic communities where drug addiction remains taboo, families in
denial about drug use and those which may be isolated and unaware of the services
and supports available in their communities. Recent events organised by the FSN are
described below.
The FSN annual work conference took place over two days in October 2010. Attended
by 365 family members and numerous practitioners and policy makers, the conference
included workshops on many topics, including family law, guardianship and custody
issues, drug addiction relapse and relapse prevention, cultural issues in the travelling
community and bereavement and addiction. A number of holistic therapy sessions
were also provided to give respite to family members affected by drug addiction. The
FSN’s newsletter reported on an unpublished evaluation of the conference, which
found that participants benefited by receiving new information, new skills, support,
healing and respite (Family Support Network 2010, October).
The FSN also organised a national campaign to coincide with the general election held
in early 2011. The aim was to bring drug use to the forefront of the election debate and
make the issue of families and communities living with drug use a political priority. It
provided a legitimate space for families and communities to articulate their concerns
about the many austerity measures being introduced in relation to drug treatment and
support services (Family Support Network 2010, December).
In February 2011, the FSN organised its 12th service of commemoration and hope. The
service is an annual religious event to mark the deaths of people from substance
misuse and related causes. This year’s event was led by the President of Ireland, Mary
McAleese. An unpublished evaluation of the service mentioned in the FSN’s recent
newsletter reports that the service provides families with an important public space to
commemorate and grieve for their loved ones (Family Support Network 2011, May).
The FSN have recently developed an initiative targeting the families of minority ethnic
groups, and of migrant communities, seeking to assist them in responding to addiction
in their families and specific cultures. As part of this work, an information day for
families of drug users from migrant communities was held.
3.2.3
Community
Headstrong is a not-for-profit organisation that works with communities and existing
mental health services in providing appropriate mental health support for young people,
and to changing how Ireland thinks about mental health issues that affect young
people. Targeting young people aged 12–25 through three levels of interventions –
universal, selective and indicated – Headstrong pursues its aims through (i) a
programme of service development to meet the mental health needs of young people,
(ii) advocacy to change the way professionals and the public perceive the mental
health of young people, and (iii) research to clarify the needs, concerns and strengths
of young people in order to inform the development of services. Headstrong has
established community-based programmes in five communities throughout Ireland
through the Jigsaw programme, which is delivered in a mix of urban and rural locations.
An update on Headstrong’s recent work is provided below (Headstrong 2010).
From 1 January 1 to 31 December 2010, 763 young people engaged with Headstrong
through two operation Jigsaw sites; Galway and Ballymun. Self-referral (28.6%) and
parent-referral (14.4%) were the most common routes to Headstrong, with other
referrals coming from second-level schools, social workers, youth programmes, adult
mental health services and peers. These diverse sources of referral suggest that
Headstrong is quite visible in the community and is viewed as a credible service to
meet the mental health needs of young people. The majority of young people
accessing the service (59.2 %, n=452) were in the 15–19 age range, and 27.9%
(n=213) were in the 20–25 age range. Just over half of all young people accessing the
service in 2010 were male (50.5%, n=385).
43
Individual case consultations, where staff in Headstrong collaborated with another
agency on behalf of young people, were provided to 33.7% (n=256) of service users;
brief contact services, including information and/or onward referral to another service,
were provided to 33% (n=251) of service users; prolonged engagement, comprising an
extensive process of working with young people to address issues and problems and
set goals, was provided to 17.9% (n=136) of service users; and brief interventions in
the form of face-to-face solution-focused encounters were provided to 14.7% (n=112)
of service users.
Headstrong places great emphasis on including young people in the design and
delivery of its programmes and has developed a youth advisory panel to enable young
people to articulate their views about the issues that concern them and how services
could be developed to address these concerns. In 2010, Headstrong launched the My
World Survey, to gather data from over 10,000 young people aged 12–25 years on
their concerns about their mental health and on what interventions and supports they
would like to see to be implemented. This research, undertaken in collaboration with
the University College Dublin (UCD), represents the first national study of youth mental
health in Ireland. To date, more than 3,000 second-level students and 3,000 third-level
students have completed the survey.
3.3
Selective prevention in at-risk groups and settings
3.3.1
At-risk groups
Eight actions in the NDS target at-risk groups and settings. Progress on three of the
actions has been deferred until the proposed National Substance Misuse Strategy is
finalised (see Chapter 1.3.1 for status report on this combined drug and alcohol
strategy). Progress has been made in relation to the other five actions.
Action 23 is about implementing Social, Personal and Health Education (SPHE) and
substance misuse policies in Youthreach Centres of Education and in Youth Encounter
Projects. These are centres that cater for early school-leavers and disadvantaged
groups and recent communication with the agencies responsible for implementation
suggest that this action is being progressed to some extent. For example, in
Youthreach and other youth projects, SPHE is provided as part of the Quality
Framework Initiative. SPHE is also provided in training centres that work with the
travelling community. In most training centres that work with early school-leavers and
disadvantaged groups, a module on substance misuse is included in the life-skills
programme and a number of staff is specifically trained to deliver substance prevention
sessions (Department of Community Equality and Gaeltacht Affairs 2011 23 March).
Action 25 is about continuing to develop facilities for both the general youth population
and those most at risk through increasing access to community, sports and school
facilities in out-of-school hours and the development of youth cafés. This action is
being progressed through funding made available through the Young Person’s
Facilities and Services Fund (YPFSF). Since 1998, the YPFSF has contributed to the
development of approximately 228 youth and community facilities in 18 target areas,
and employed 420 people. In 2010 the YPFSF allocated funding of €26.15m to assist
in developing youth facilities and services (Department of Community Equality and
Gaeltacht Affairs 2011 23 March)
Some progress has been reported in relation action 24 – co-ordinating the activities
and funding of interventions in out-of-school settings – and plans are in place to
implement a uniform set of drugs and alcohol education standards to enhance the
quality and consistency of service provision (action 26) (Department of Community
Equality and Gaeltacht Affairs 2011 23 March).
Action 31 seeks to maintain the focus of existing programmes targeting early schoolleavers. Measures underpinning this action are mainly delivered through the Delivering
44
Equality of Opportunity in Schools (DEIS) programme, which aims to improve
attendance, participation and retention is designated schools located in disadvantaged
areas. Support has been provided to approximately 151,000 children in 876 schools;
46,000 at risk children are directly targeted in schools through the Home School
Community Liaison and School Completion programmes. The School Completion
Programme targets those most at risk of early school-leaving as well as those who are
already outside of the formal system. This includes in-school, after-school and holidaytime supports (Department of Community Equality and Gaeltacht Affairs 2011 23
March).
Despite the measures outlined above that have been implemented through the DEIS
programme, it appears that early school-leaving remains an intractable problem.
According to the Children’s Rights Alliance (Children's Rights Alliance 2011b), which
rates the performance of government measures on a range of social policy issues on
an annual basis, early school-leaving receives a ‘D’ grade, down from a ‘C’ in 2010.
(Children's Rights Alliance 2011b)The drop reflects the failure to constructively address
this problem, despite its persistent nature and long-term impact, and the slow pace of
implementing the proposed new, integrated National Education Welfare Board
(NEWB).
Some of the measures delivered through the DEIS programme aim to improve literacy
and numeracy levels among disadvantaged students. A recent report has noted that
literacy achievement among 15-year-old children has been declining in Ireland when
compared with other countries (Children's Rights Alliance 2011a). This report claims
that under the Programme for International Student Assessment (PISA), Ireland’s
ranking dropped from 5th among 39 OECD countries in 2000 to 17th in 2009. An
evaluation of the DEIS programme is due to be completed towards the end of 2011.
Leahy (Leahy, et al. 2011) reports on a case study of a community-based drugs project
located in a disadvantaged community. The aim of the work was to assess the
performance of the Gurranabraher–Churchfield Drugs Outreach Project in Cork and its
use of youth workers to provide services to clients at all levels of the 4-tiered drug
treatment model.
The main conclusions were:
 A social rather than medical or legal response to drugs issues offers policy
makers and practitioners a genuinely holistic methodology for effective
intervention.
 A local rather than a universal response rooted in harm reduction
allows cultural, geographical and community factors to dictate the
nature of an intervention.
 Effective practice in this field requires skilled, independent, reflexive,
motivated and creative practitioners operating within a supportive
agency setting.
 A clear theoretical framework encompassing knowledge of young
people, drugs work, human behaviour and communities is a
fundamental prerequisite to best practice.
 A high degree of service visibility in the community and easy access to
the services is required.
 Community-based projects work effectively with service users who will
never enter treatment; they offer drug users an effective alternative to
medicalised responses.
 In many cases inappropriate and problem drug use is a consequence of
social inequality; interventions that can respond to these social issues
in (particularly disadvantaged) communities offer the people who suffer
from drugs issues a far more comprehensive range of services than a
medicalised response.
 Human contact between the service user and the practitioner in the
form of a relationship founded on trust is the key building block of
success.
45

3.3.2
In terms of cost effectiveness, community-based projects offer excellent
value for money; the overwhelming majority of funding is used in the
provision of frontline services.
At-risk families
The Strengthening Families Programme (SFP) has been delivered to a number of atrisk families in local drugs task force areas. The SFP is an internationally recognised
parenting and family skills initiative for high-risk families that focuses improving existing
strength within the family.
Howley (Howley and Kavanagh 2010) reports on an evaluation of one particular
iteration of the SFP in Ballyfermot, an area designated as a local drugs task force area.
Eleven families, including 12 parents, two grandparents and 20 young people aged
between 11 and 17 years engaged with the 15-week programme; ten families
completed the programme and graduated. Three sessions were run on a weekly basis
– one targeting parents, one targeting young people and one targeting both parents
and young people. Data collection methods included semi-structured interviews with
families towards the end of the programme.
All the families that graduated from the programme self-reported that their
communication skills improved; all the parents self-reported improvements in their
ability to parent; the majority of young people self-reported an improvement in their
relationships with their parents and all of them self-reported a reduction in conflict
within the family home; the majority of parents and young people self-reported greater
understanding and respect for each other. All the families that completed the
programme would recommend it to other families. The group leaders who delivered the
programme were praised for their skills and professionalism; the coordinator was
praised for managing and organising the delivery of the programme and an
improvement in relations within the community and between the different agencies
involved was also reported.
3.3.3
Recreational settings (incl. reduction of drug and alcohol related harm)
See National Report 2010 for most recent information (Irish Focal Point 2010).
3.4
Indicated prevention
3.4.1 Children at risk with individually attributable risk factors (e.g. children with
AD(H)D, children with externalising or internalising disorders)
The Child and Adolescent Mental Health Services (CAMHS) is a specialist service that
works with young people aged 0-18 who present with mental, emotional and
behavioural problems. The CAMHS currently have 50 teams providing communitybased services, using a multi-disciplinary approach which includes psychiatrists, social
workers, clinical psychologists, occupational therapists, speech and language
therapists and nurses. The HSE recently published the results of a clinical audit
undertaken by the 50 CAMHS teams during November 2009 (Health Service Executive
2010). During the month, 6,950 cases were seen by the teams with 89.5 of cases
returns. The clinic in the community was the main setting for appointments (92.5%),
with the school being the setting for 3.6%, and the home the setting for 1.2%; 67.9% of
cases was male. Information on the conditions that young people presented with are
included in Table 3.4.1.1.
Table 3.4.1.1: Mental health and behavioural problems among young people presenting to the Child
and Adolescent Mental Health Services (CAMHS), November 2009 *
Primary presentation
Number
Hyperkinetic disorders/problems included ADHD
2,303
Anxiety disorders/problems included anxiety, phobias, somatic
1,122
complaints, obsessive compulsive disorder, post traumatic stress
disorder
Depressive disorders/problems
612
46
%
33.1
16.1
8.8
Primary presentation
Conduct disorders/problems included oppositional defiant behaviour,
aggression, anti social behaviour, and fire-setting,
Eating disorders/problems included pre-school eating problems, anorexia
nervosa, and bulimic nervosa
Deliberate self harm included lacerations, drug/medication and alcohol
overdose
Psychotic disorders/problems included schizophrenia, manic depressive
disorder, or drug-induced psychosis
Substance abuse, drug and alcohol misuse
Number
604
%
8.6
194
2.8
188
2.7
73
1.1
53
0.8
Source: (Health Service Executive 2010)
*A small number of conditions that young presented with are not included in the table.
Teen counselling
Teen Counselling helps teenagers to negotiate the transition from childhood to early
adulthood and works with families to enable them to manage the transition. The
counselling service is provided by a psychologist and a social worker for each family
using the service; the service operates in five different locations within Dublin. The
average time from first appointment to case closure is 8 months duration including 9
counselling sessions made up of 27 clinical hours.
Teen Counselling is one of few interventions working with teenagers and their families
in Ireland that publishes an annual report. The report is valuable in that it provides a
profile of teenagers with behavioural problems who are using support services. Its
latest annual report (Crosscare 2010) updates the profile for 2009.
In 2009, 431 teenagers and their families were referred to the counselling service and
95% were accepted onto the waiting list. In total, 399 teenagers and their families
availed of the service; 248 were new referrals. Of these new referrals, 56% were under
16 years, 53% were female and 41% were living with both their biological parents, 37%
reported using alcohol and 13% used drugs, primarily cannabis. Thirty-five per cent of
new referrals were referred for counselling to address behavioural problems in the
home, 35% owing to family conflict and 26% to address behavioural problems in
school. Thirty-one per cent reported problems with anxiety, and self-harm was an issue
for 17%. The report notes that the percentage of teenagers who reported using drugs
has fallen in recent years; however, many reported addiction problems in their families,
particularly among their fathers.
Assessment was undertaken from baseline to exit, using the Children’s Global
Assessment Scale (CGAS) to assess problem severity and change in teenagers, and
the Global Assessment of Relational Functioning DSM-IV (GARF) to assess family
functioning. Improvement was noted in 45% of the families that attended the service in
2009. From a group of 62 parents that were asked to provide a self-assessment of their
work with the programme, the vast majority noted a reduction in the severity of the
problems they presented with and an improvement in their ability to cope. A group of
51 teenagers who completed the programme were asked to self-report changes in the
severity of the main problem they reported with and the impact of this problem on four
areas of their life. Eighty-five per cent (n=43) self-reported improvement in the severity
of their main problem when in school, 89% (n=45) noted improvement in their problem
when at home, 76% (n=39) reported improvement in their main problem in themselves
(the self) and 54% (n=27) noted improvement in severity of their main problem when
with their friends. However, 46% (n=23) reported no change in problem severity when
interacting with their friends.
Inter-agency working with young people
Inter-agency work between the statutory, voluntary and community sectors has in
recent years become an important theme in policy development and practice in public
services in Ireland. On behalf of the Children Acts Advisory Board (CAAB), Duggan
and colleagues (Duggan and Corrigan 2009) undertook a literature review of interagency work in Ireland in public services, with a particular focus on work undertaken in
the children’s sector. The authors also reviewed a small select number of international
studies for comparative purposes. The authors talk about their disappointment at
47
finding a limited amount of research and evaluation in the field, despite extensive
searches. They also point out that much of the literature focuses obstacles to interagency working and the actors involved, and not so much on issues such as the
objectives of inter-agency working or the merits of various models of inter-agency
working. As a result, the authors concluded that the available literature did not help in
identifying what good practice might be and, in the context of these limitations, they
cautioned against the ‘uncritical consensus’ that inter-agency working is a good thing.
Developing good practice for children in care
The Children’s Act Advisory Board has developed a set of best-practice guidelines for
the use of therapeutic interventions for children and young people in out-of-home care
(Childrens Act Advisory Board 2009). This work was undertaken in response to
concerns relating to the use of therapeutic interventions in residential centres for
children; the concerns included the appropriateness and efficacy of some interventions
and how they were evaluated. The guidelines comprise seven sections and provide for
a needs assessment, identifying appropriate therapeutic intervention and measures to
enhance implementation, implications for current practice and how to evaluate and
assess outcomes.
Providing services for children with behavioural problems
The National Children’s Strategy (Department of Health and Children 2000) contains
two specific actions to improve services for children at risk, where emotional and
behavioural problems are causing concern. The Children’s Rights Alliance, in its recent
review of the strategy, provides an update on progress made so far towards
implementing these two actions (Children's Rights Alliance 2011a).
Action 26 – A National Educational Psychological Service (NEPS) will be provided to all
schools.
CAAB reports that access to NEPS is now available to all schools. It goes on to state,
‘In 2008/09 NEPS psychologists were assigned to 74% of primary schools and 92% of
post-primary schools. Schools that do not have an assigned NEPS psychologist can
commission private psychological assessments but this function is limited and they do
not have access to follow up supports. In 2010, the number of NEPS psychologists was
capped at 178: in December 2010, the number stood at 164. Although much progress
has been made during the 10 year period, the NEPS service is still struggling to meet
demand from the schools.’
Action 81 – Introduce more structured programmes for the identification, assessment
and management of children with emotional and behavioural difficulties (to ensure a
comprehensive response based on individual case plans).
CAAB states, ‘It is understood (anecdotally) that initiatives introduced by the National
Education Welfare Board (NEWB) and NEPS have made a positive difference to those
children’s lives that have engaged with them; however neither have yet been subject to
evaluation.’
3.5
National and local media campaigns
Action 27 in the NDS aims to further develop a national website to provide fully
integrated information and access to a national helpline. This action is being
progressed and the new version of www.drugs.ie went live in May 2010 as a one-stopshop for drug and alcohol information and support. The site includes comprehensive
information on drugs and alcohol; a database of treatment and rehabilitation services
operating in Ireland; drug and alcohol support guides and booklets; multimedia section
for broadcasting audio and video podcasts; Drugs.ie Bulletin; and core content in
eleven languages.
In 2010, the HSE launched its national drug awareness campaign ‘Legal or illegal highs
– they’re anything but safe’. Aimed primarily at people aged between 15 and 40 years,
48
the campaign messages regarding the unsafe nature of legal highs were carried on
posters and t-shirts, and in a Z-folded wallet card. They also featured on radio ads, in
cinemas, in ‘pop-ups’ on Facebook, in washrooms in bars and clubs, and at festivals
over the summer. The campaign was developed in consultation with all the key
stakeholders, including the target audience. The campaign also included an information
booklet for parents and guardians. The booklet explains what legal highs are and the
current legal issues, and offers some basic advice on how to talk to young people
about these drugs and what to do if they are using them. It includes information on
harm reduction and on what to do if someone is having a bad reaction to a drug.
49
4.
Problem Drug Use (PDU)
4.1
Introduction
This chapter provides an overview of developments and trends in the prevalence and
characteristics of problem drug users (PDUs) in Ireland ranging from data for 2006
relating to the prevalence estimate of PDUs, to more recent studies relating to data on
problem drug users from non-treatment sources and on varieties of problematic drug
use. A PDU is defined as an ‘injecting drug user or long duration/regular user of
opiates, cocaine and/or amphetamines’ (EMCDDA 2004).
It is not possible to estimate the number of injecting drug users or PDUs, apart from
opiate users, in Ireland as the National Drug Treatment Reporting System (NDTRS)
does not use a unique identifier. This issue has been raised in strategy submissions
and it is hoped that it will be addressed in the forthcoming health information bill. Three
sources containing information indicative of the nature of problem drug use in Ireland
have been used to date.
A national 3-source capture-recapture (CRC) study, to provide statistically valid
estimates of the prevalence of opiate drug use in the national population during 2006,
was commissioned by the National Advisory Committee on Drugs (NACD). This is
described in detail Section 4.2.1 below. The most recent study (2006) indicates that
use has increased since the previous survey (2001). There were 11,807 known opiate
users in 2006. The major expansion of the national methadone treatment programme
between 2001 and 2006 is the main reason for the inflation of the figures. There is
some doubt over the estimate produced of a possible further 8,983 opiate users who
have not come into contact with any of the drug treatment services, hospital in-patient
services or the Gardaí.
The following are among the trends (2001–2006) seen in the study results:
 the rate of opiate use among females and males aged 15–24 decreased, indicating
a significant reduction in the number of young people commencing opiate use,
 an increase in opiate use outside of Dublin, and
 a higher proportion of opiate users in treatment in Dublin than elsewhere, reflecting
the more recent spread of opiate use outside Dublin and the later development of
treatment services.
The NACD will be able to estimate the number of people dependent on cannabis in the
year prior to the survey using data from the general population survey on drug use
2010/11 (Jean Long, NACD committee member, 2010). The questionnaire has two
measures of cannabis dependency, the MCIDI based of clinical diagnosis and the SDS
used in a number of studies on treatment.
4.2
Prevalence and incidence estimates of PDUs
4.2.1
Indirect estimates of problem drug use
Problem opiate users in Ireland
An opiate is a drug containing opium or any of its derivatives which acts as a sedative
and narcotic. Examples include heroin, methadone, morphine, codeine, hydrocodone,
oxycodone, fentanyl and tramadol. Heroin is synthesised from morphine, a naturally
occurring substance extracted from the seed pod of the Asian opium poppy plant.
Heroin is available in three forms – a white powder, a brown powder, or a black sticky
substance, known as ‘black tar heroin’.
In a repeat of a prevalence study in 2001 (Kelly, et al. 2003), Dr Alan Kelly and
colleagues estimated the prevalence of problem opiate users in Ireland in 2006 using a
three-source CRC method (Kelly, et al. 2009). Data from the three sources – the CTL,
50
the HIPE scheme and the Garda PULSE data5 – indicated that there were 11,807
opiate users aged 15–64 years known to services in Ireland in 2006, and an estimated
8,983 users not known to the services (hidden population) (Table 4.2.1.1). These data
were presented in Standard Tables 7 and 8 in 2009. The national prevalence estimate
of opiate users in 2006 was between 18,136 and 23,576; the point estimate was
20,790 (Table 4.2.1.2). This estimate is likely to be inflated. The respective rates per
1,000 of the 15–64-year-old population in Dublin and in the rest of Ireland are 17.6 and
2.9. These estimated figures are likely to be inflated because the population was not
closed, that is, it continued to recruit significant numbers of people into treatment (in
Dublin and outside Dublin) and police custody (outside Dublin) in 2006. In addition, the
overlap between the three population sources was small. These two factors are known
to inflate estimates obtained by the CRC method. Of the estimated number, 28%
(5,886) lived outside Dublin and 72% (14,904) in Dublin.
Table 4.2.1.1 Number of opiate users known, estimated number hidden, prevalence estimate and
population rate in Ireland, in Dublin and in the rest of Ireland, 2006
Known
Estimated
Estimated
Rate/1,000
Age group
number
number hidden
prevalence
population
Ireland
15–64
11,807
8,983
20,790
7.2
Dublin
15–64
9,442
5,462
14,904
17.6
Rest of
Ireland
15–64
2,365
3,521
5,886
2.9
Source: (Kelly, et al. 2009)
Table 4.2.1.2 Estimated prevalence of opiate use in Ireland, in Dublin, and in the rest of Ireland,
2001 and 2006
2001
2006
Lower
Upper
Rate/1000
Lower
Upper
Rate/1000
Estimate
bound
bound
population
Estimate bound
bound
population
Ireland
14,681
13,405
15,819
5.6
20,790
18,136
23,576
7.2
Dublin
12,456
11,519
13,711
15.9
14,904
13,737
16,450
17.6
Rest of
Ireland
2,225
1,934
2,625
1.2
5,886
4,399
7,126
2.9
Source: (Kelly, et al. 2003); (Kelly, et al. 2009)
The national point estimate increased by 42%, from 14,681 in 2001 to 20,790 in 2006.
The point estimate for Dublin increased by 20%, while the point estimate for the rest of
Ireland increased by 165% – albeit from a low estimate in 2001. The rate of opiate use
per 1,000 of the 15–64-year-old population living outside Dublin increased from 1.2 in
2001 to 2.9 in 2006.
Table 4.2.1.3 shows the 2006 estimate by age, gender and place of residence.
Seventy-one per cent were male. One in five (21%) was between 15 and 24 years old
and half (51%) were between 25 and 34 years old. In Dublin, the rate of opiate use per
1,000 of the 15–24-year-old female population decreased by 62%, from 18.7 in 2001 to
7.2 in 2006, which indicates that the number of younger women commencing opiate
use has decreased. A smaller but still notable decrease in the rate of opiate use in
Dublin was seen among males aged 15–24 years.
In an unpublished study, Kelly and colleagues report that retaining opiate users in
treatment reduces their likelihood of being in contact with the Gardaí (Dr A Kelly,
personal communication). For example, only 12% of males aged 25–34 years who
were known to the Gardaí in 2001 and were attending treatment services between
2001 and 2006 were reported to be committing crime in 2006. This is in line with
findings from the ROSIE study and indicates that methadone treatment reduces the
incidence of crime.
Table 4.2.1.3 Prevalence estimate by age, gender and place of residence, 2006
Gender
Age group
Ireland
Dublin
Rest of Ireland
All
15–64
20,790
14,904
5,886
Males
5
15–64
14,787
10,395
4,392
See Chapter 5.1, 6.1 and 9.1 for a description of these three data sources.
51
Gender
Age group
15–24
25–34
35–64
Ireland
3,150
7,238
4,399
Dublin
1,892
5,172
3,331
Rest of Ireland
1,258
2,066
1,068
Females
15–64
15–24
25–34
35–64
6,003
1,159
3,298
1,546
4,509
701
2,605
1,203
1,494
458
693
343
Source: (Kelly, et al. 2009)
Research on data sources and methods
The NACD commissioned a study team (Maria Gannan and Gordon Hay) to investigate
and report on methods and data sources which can be used to estimate the number of
problem opiate and cocaine users and the prevalence of problematic opiate and
cocaine use in Ireland. The objectives of the study were to:
 determine indirect statistical approaches to estimating numbers and rates of
problematic opiate and cocaine users in Ireland,
 identify statistical or practical adaptations that would improve the reliability of the
current CRC estimate,
 identify all data sources in Ireland, which can be used in the estimation of the
prevalence of problematic opiate and cocaine use and, using a systematic
approach, evaluate their potential for use, and
 design pilot studies to test the preferred approaches.
While not yet published, the study team have made the following recommendations for
estimating the prevalence of opiate / cocaine use in Ireland:
A combination of estimation methods should be used to calculate the prevalence of
opiate use, with 4-sample CRC being the main method. A 4-sample CRC analysis
should be carried out in all 26 counties; where it is not possible to calculate an estimate
using CRC, either Multiple indicator method or multiplier methods should be used. The
study team favour a 4-sample CRC analysis as this produces more robust estimates
than a 3-sample analysis. The four suggested samples are CTL, HIPE, PULSE and
Probation Service data. If this approach, were used, each county would have a local
estimate, and estimates could be produced for other geographical areas of interest
such as HSE region or Probation Service area.
A pilot study using the recommended approach would not be an effective use of time
and resources. Studies using the CRC method to estimate opiate prevalence generally
comprise two phases – a data access and collection phase and an analysis phase. The
first phase needs the most time and resources. The time and effort are not related to
the amount of data being collected, so piloting data collection for only a few areas
would not significantly reduce the time or cost involved. While a pilot study could
investigate issues relating to the data, any possible issues could only be investigated
once the data had been collected and the analysis begun; thus, a pilot study would still
require the same amount of time and effort as a full study but without the benefit of
comprehensive results.
A geographical unit of analysis needs to be identified in order to carry out a successful
study. In order for the CRC method to be successful, analyses need to be carried out at
a sufficiently ‘local’ level; stakeholders such as data providers would find local-level
estimates useful for planning purposes. It is also important that the data refer to area of
residence and not area of contact; for example, Garda (police) data should record the
area of residence of the offender not the area where the offence was committed.
Following round-table discussions with a group of prospective data providers
(excluding Dublin and Tipperary), county level was identified as the preferred
geographical area. These county estimates could be combined to give estimates at the
level of HSE region or Garda region, or to give a national estimate. Administrative
geography indicates that Tipperary should be broken in two - into north and south
ridings; the unit of analysis for Dublin requires further analysis taking into account the
52
River Liffey and HSE local health office, drugs task force and local authority area
boundaries.
In order for the study to be timely, cost effective and successful, research governance
need to be improved. The data required to match successfully across sources in a
CRC analysis are an individual’s initials, date of birth, and gender. Encryption can be
used to transform this data into an unrecognisable code prior to transfer from data
provider to researcher. However, as with any research of this nature, ethical approval is
required. The different data providers will also need information on data security and
the procedures for safe disposal of the data once the study is completed. Previous
CRC studies in Ireland have involved numerous ethics applications to access HIPE
data from different hospitals around the country. This has led to significant delays and
was a waste of time and resources. The study team recommend that the NACD
together with data providers investigate streamlining research governance. Moreover,
prior to any future prevalence work, a concerted effort should be made to raise
awareness among stakeholders about the nature of prevalence estimation, the data
required and the benefits of the resulting estimates.
Use a different method to estimate cocaine prevalence. Owing to the nature of powder
cocaine use and the fact that cocaine users can be identified through current Irish data
sets, the study team recommend a different method of prevalence estimation than that
suggested for opiate use. For example, a heroin user who appears in PULSE data is in
the same cohort as an opiate user appearing in the HIPE data, but the same cannot be
said of a user of powder cocaine. As a result, CRC cannot be used to produce a valid
estimate of cocaine users. The study team recommend using a combination of large
household survey data and data from a longitudinal study of substance misuse, to
model the different levels of powder cocaine use within the Irish population.
Health Information Bill
In June 2008 the Department of Health and Children (DoHC) launched a public
consultation on a health information bill. The DoHC prepared a thematic synopsis
setting out the main points raised. With regard to public opinion on a unique personal
identifier for individual health records and health-related information systems, there
was general support but many commentators (including the Data Protection
Commissioner) recommended that this identifier should not be the PPSN used for
taxation and social welfare purposes. It was also recommended that confidentiality and
privacy be protected in any new system (Department of Health and Children 2009, 09
January). As part of its commitment to the consultation process and in line with the
philosophy of engaging with individuals in Your Service, Your Say,6 the DoHC in
conjunction with the Health Service Executive (HSE) and the Health Services National
Partnership Forum, held a consultative workshop on 20 January 2009. Once again
there was general support for a unique identifier in health-related records but many
people had reservations about the use of the PPSN (without specific protections) as
the identifier, principally because of linkages fears.
The new government elected in early 2011 has included a health information bill in its
legislative programme; the government notes that the heads of the bill have been
agreed, the text is being drafted and the bill is expected to be published in mid-2012.7
4.2.2
Estimates of incidence of problem drug use
No Information available.
6
The Office of Consumer Affairs has responsibility for developing and implementing best-practice models of customer
care within the HSE and promotes service user involvement throughout the organisation through the concept of 'Your
Service Your Say'.
7
See Section B of the Government Legislation Programme at www.taoiseach.ie , accessed on 4 October 2011. The
purpose of the bill as stated in the new Government Legislation Programme is ‘to provide a legislative framework for the
better governance of health information so as to enhance individual patient care and safety and achieve wider health
service goals and to provide for a streamlined structure for multi site health research ethics approval’.
53
4.3
Data on PDUs from non-treatment sources (police, emergency,
needle exchange etc)
4.3.1
PDUs in data sources other than TDI
Health of users of Simon Community services: a ‘snapshot’ study
The Simon Communities of Ireland (Simon Communities of Ireland 2010) published a
report on health and homelessness in late 2010. This report presents the findings of a
‘point in time’ survey undertaken over a one-week period, between 26 July and 1
August 2010, at all eight Simon communities in Ireland. The survey collected data on
the profile and health needs of people accessing Simon projects and services.
Participants were selected through convenience sampling, i.e. they were selected
because they were readily available. This type of sampling gives insights into the
health needs of a proportion of the service user population but cannot be generalised
to the health needs of the wider homeless population. Data were collected in face-toface interviews and in a review of the records of the 788 participants, including those
who were currently homeless, those who had been homeless and needed support to
maintain their current home, and those who were at risk of becoming homeless.
The sample’s profile was as follows:
 78% were male;
 85% were Irish, 6% British, 5% Eastern European and 1.4% Irish Travellers;
 9% were aged between 18 and 25, 21% between 26 and 35 years, and 54%
between 36 and 55;
 51% received a disability allowance and 6% received the old age pension;
 6.5% were classified as not being habitual residents; and
 65% were registered as homeless with a local authority.
Of the 769 people who answered the question about alcohol and drug use, 66%
reported consuming alcohol. Fifty-five per cent of respondents had physical
complications as a result of alcohol use. Of the 768 responses, 38% reported using
drugs other than alcohol; heroin was the most common other drug used, followed by
cannabis (see Table 4.3.1.1). Thirty-one per cent of respondents who used drugs were
using two drugs at the same time and 25% were using three drugs. Fifteen per cent
(115) of all respondents were intravenous drug users. Seventy eight respondents were
tested for blood-borne viruses.
Table 4.3.1.1 Drugs most commonly used by service users, Simon Communities in Ireland, 2011
(n=768)
n
%
Heroin
159
20.7
Cannabis
116
15.1
Benzodiazepines (prescription status not reported)
94
12.2
Head shop substances
54
7.0
Methadone (unprescribed methadone)
53
6.9
Cocaine
17
2.2
Other
24
3.1
Unknown
13
1.7
Source: (Simon Communities of Ireland 2010)
Drug use in the Canal Communities area: an ethnographic study
The Canal Communities Local Drugs Task Force (CCLDTF) covers Rialto, Bluebell and
Inchicore communities in the Dublin 8 area. The CCLDTF undertook a study to improve
knowledge and understanding of the nature of illicit drug use in the area (Saris and
O'Reilly 2010). The researchers used an ethnographic method, which they stated ‘can
be defined as a perspective as well as a means of data collection’ (p. 12).
Data for the CCLDTF study were collected by means of participant observation (in
service facilities, estates and homes) and through interviews. Fifty-one interviews were
conducted, of which 24 were life histories and eight were group discussions (with 29
54
young people). Six of those who were initially interviewed had a subsequent interview.
Additionally, there were 24 formal and informal interviews with service providers. The
authors noted that many other people interacted with the research at all the different
sites. Interviewers also administered a survey to a target population of 100 opiate or
methadone users.
The report begins with a discussion on the nature of drug use and the difficulties in
relation to the categorisations used in the field. In relation to patterns of use, the
authors use the term ‘styles’ as this can help convey how ‘…at any one moment,
populations that overlap certain institutional categories (disorganized heroin-users, for
example, can be found both in and out of treatment, often using both methadone and
heroin simultaneously), while presenting different challenges to various intervention
strategies’ (p. 19). This is followed by a chapter which discusses reported experiences
of the combined use of heroin and methadone. Subsequent chapters deal with the
history and the issues around drug use in the area, the emergence of crack cocaine
and the changing patterns of drug use. Data from the CTL pertaining to people living in
the CCLDTF area were analysed. One finding from this analysis was that the area had
a relatively high rate of registration on the CTL in 2007, at 20 per 1,000 of the
population, compared to 2 per 1,000 of the population nationally.
One hundred people were recruited for the survey. The quantitative data collected from
92 valid responses to the survey were summarised in an appendix to the report. (Eight
questionnaires were deleted from the analysis as they were either repeats or the
respondent no longer used methadone or heroin.) The main findings were as follows:
 63% were male;
 80% were 28 years or older;
 27% did not complete Junior Certificate, the lowest level of second level education;
 76% of those interviewed said they had children, giving a total of 156 children, with
about half (76) living with the respondents;
 11% were in current employment;
 98% were prescribed methadone, indicating a history of problem drug use;
 average number of days on methadone was 86 and average dose was 86ml;
 63% reported use of heroin in the last three months (current use);
 46% reported current use of street benzodiazepine;
 30% reported current use of crack;
 22% reported current use of powder cocaine;
 17% reported current use of street methadone;
 70% had injected drugs in the past, with 27% having injecting in the past three
months and 60% of those who injected reporting sharing a needle or syringe;
 36% reported spending in an average week between €60 and €119 on drugs;
 88% reported ever having been involved in crime; and
 57% reported having had a custodial sentence.
The authors noted that most of those interviewed were polydrug users, often using
combinations of illegal and legal drugs (whether obtained legally or not). The following
is taken from the researchers’ field notes: ‘Louise is 34 years old. She finished her
Community Employment (CE) scheme recently. She lives with her sister. Louise is on
methadone and prescribed sleeping tablets and an antidepressant. She smokes a
couple of bags of heroin every few days. Recently, she has been smoking crack every
day. This is her main problem drug at the moment. Her weight loss is noticeable.’ (p.
18)
Many of those who took part in the study and who were in treatment for opiate use also
used cocaine, with the use of crack cocaine emerging as a problem. An interviewee,
‘Sandra’, explained: ‘I got a pipe off someone and I says, ah that’s not doing me any
harm, [be]cause it was really the needles [to inject cocaine] that was doing the harm,
the blood poisoning, septicaemia, so I says ah I’ll have a pipe [of crack] and then I went
to have another one, …going half with someone, and when I was going well, I would
55
get one for meself. ‘Just one’, I’d say, ‘and I’ll go down and have a nice smoke at the
end of the night,’ to meself. …and I was smokin’ every morning and all.’ (p. 42)
Heroin use was viewed unfavourably by younger drug users, as one interviewee, ‘Kim’,
explained: ‘You know what I mean, when you hear about new drugs coming out and all
these mad trips and you’d say oh I have to try this, it’s an experience, but we never turn
round and say, ‘I have to try heroin and see what that’s like’, d’ya know what I mean?’
(p. 53)
The authors found that many of those in treatment for problem opiate use had a range
of unmet needs. They also found that individuals who dealt drugs often continued to do
so after entering treatment.
While terms and categories used in government policy such as ‘drug user’ and
‘treatment’ appear clearly defined, particularly in relation to funding, their application at
local level is less clear, causing a ‘divide [that] needs to be bridged’.
Substance use among HIV infected people
In a recently published study, the characteristics and behaviours of people with HIV
living in Ireland and in Australia are compared (O'Connor, et al. 2010). The data were
collected between June and December 2005 and the participants were asked about
tobacco, alcohol and other drug use. The average age of the respondents in Ireland
was 36.2 years, and in Australia 45.3 years. Sixty-seven per cent of the study group in
Ireland were men, while 98% of those in Australia were men. Forty-seven per cent of
the participants in Ireland were Irish and 42% were African. Two thirds of the
participants in Australia were Australian and 16% were New Zealanders. Table 4.3.1.2
summarises the responses regarding substance use. Forty-two per cent of participants
in Ireland reported using recreational drugs at some point in their life; seven
respondents reported ever injecting, and four reported a history of drug dependence.
Fifty-four per cent reported smoking tobacco at some point in their life, and 72% drank
alcohol at some point in their life, and 9% of these reported a history of alcohol
dependence.
Table 4.3.1. 2 Substance misuse among HIV patients, Ireland and Australia, 2005
Ireland
Australia
n (%)
n (%)
Recreational drugs
Current use
12 (13)
61 (41)
Past use
28 (29)
46 (64)
Admits addiction
7 (18)
18 (18)
Admits injecting drug use
4 (10)
18 (18)
Tobacco
Current use
34 (37)
55 (37)
Past use
16 (17)
38 (26)
Never used
42 (46)
54 (37)
Alcohol
Current use
49 (52)
107 (77)
Past use
29 (30)
27 (19)
Never used
18 (19)
6 (4)
Admits addiction
7 (9)
11 (8)
Source: (O'Connor, et al. 2010).
4.4
Intensive, frequent, long-term and other problematic forms of use
4.4.1 Description of the forms of use falling outside the EMCDDA’s PDU
definition (in vulnerable groups)
No new Information.
4.4.2 Prevalence estimates of intensive, frequent, long term and other
problematic forms of use, not included in the PDU definition
The NACD will be able to use data from the general population survey on drug use
2010/11 to estimate the number of people dependent on cannabis in the year prior to
56
the survey (Jean Long, NACD committee member, 2010). The questionnaire has two
measures of cannabis dependency, the MCIDI based of clinical diagnosis and the SDS
used in a number of studies on treatment.
57
5.
Drug-related treatment: treatment demand and treatment
availability
5.1
Introduction
Two broad philosophies underlie the approaches to drug-related treatment in Ireland:
medication-free therapy and medication-assisted treatment. Medication-free therapy
uses models such as therapeutic communities and the Minnesota Model, though some
services have adapted these models to suit their particular clients’ needs. Medicationassisted treatment includes opiate detoxification and substitution therapies, alcohol and
benzodiazepine detoxification, and psychiatric treatment. Various types of counselling
are provided through both philosophies of treatment and independent of either type of
treatment. Alternative therapies, such as acupuncture, are provided through some
community projects.
The Health Service Executive (HSE), which manages Ireland’s public health sector,
provides an addiction service, including both illicit drugs and alcohol, delivered through
Social Inclusion Services, which is part of its Integrated Services Directorate. Addiction
treatment services are provided through a network of statutory and non-statutory
agencies. Some of the principal non-statutory agencies include:
The National Drug Rehabilitation Implementation Committee (NDRIC) is
responsible for overseeing and monitoring the implementation of the recommendations
contained in the report of the Working Group on Drugs Rehabilitation, the development
of protocols, service level agreements and a quality standards framework, and
ensuring appropriate training is instigated. Chaired by the HSE, the NDRIC comprises
representatives of the HSE, government departments, agencies and community and
voluntary sector organisations, the National Advisory Committee on Drugs, service
professionals, problem drug users and families of problem drug users.
The Ana Liffey Drug Project (ALDP) is a ‘low threshold - harm reduction’ service,
based in north inner city Dublin. The project works with people, experiencing addiction,
to minimise the harm that problematic drug use causes them, their families and the
wider community.
Coolmine Therapeutic Community provides a comprehensive range of programmes
designed to support and empower individuals and communities affected by alcohol and
drugs. It was one of the first dedicated rehabilitation centres offering a range of vital
support services to people all over Ireland.
Crosscare, formerly known as the Catholic Social Service Conference, provides
homeless, community and young people’s services. Its Drug and Alcohol Programme
aims to help individuals, families and communities to prevent and/or address problems
arising from drug and alcohol use.
Merchants Quay Ireland (MQI) is a voluntary organisation, based in South Inner City
Dublin, which provides a wide range of services to homeless people and drug users.
Progression Routes, located in ALDP’s premises in north inner city Dublin, seeks to
improve service delivery to those attending drugs services. It does this by working with
multiple agencies to formulate and implement strategic interagency solutions to
identified barriers to progression.
In 1998 a Methadone Treatment Protocol (MTP) was introduced, to ensure that
treatment for opiate misuse could be provided wherever the demand exists. New
regulations pertaining to the prescribing and dispensing of methadone were introduced,
and a joint Health Board/Irish College of General Practitioners (ICGP) committee was
formed to provide training, ongoing education and regular audit for general practitioners
58
(GPs) taking part in the programme. Under this protocol, any GP wishing to take part in
the provision of treatment services to drug users, must undertake training as provided
by the ICGP. Under the MTP, GPs are contracted to provide methadone treatment at
one of two levels – Level 1 or Level 2. Level 1 GPs are permitted to maintain
methadone treatment for misusers who have already been stabilised on a methadone
maintenance programme. Each GP qualified at this level is permitted to treat up to 15
stabilised misusers. Level 2 GPs are allowed to both initiate and maintain methadone
treatment. Each GP qualified at this level may treat up to 35 misusers. Practices where
two Level 2 GPs are practising are permitted to treat up to 50 misusers. Locally-based
methadone treatment for opiate misusers is now provided through drug treatment
clinics, satellite clinics or through GPs in the community.
Under the Community Pharmacy Contractor Agreement the HSE can agree with
individual pharmacies to dispense methadone mixture DTF1mg/ml to opiate dependent
persons in their local areas on a special methadone prescription form. The involvement
of community pharmacists in the dispensing of methadone also ensures that a large
number of opiate dependent persons may be treated in their own local areas.
Data on drug treatment in Ireland are collected through two national data collection
tools – the National Drug Treatment Reporting System and the Central Treatment List.
The National Drug Treatment Reporting System (NDTRS) is a national
epidemiological database which provides data on treated drug and alcohol misuse in
Ireland. The NDTRS collects data from both public and private outpatient services,
inpatient specialised residential centres and low-threshold services. For the purposes
of the NDTRS, treatment is broadly defined as ‘any activity which aims to ameliorate
the psychological, medical or social state of individuals who seek help for their
substance misuse problems’. The NDTRS is a case-based, anonymised database.
The NDTRS is co-ordinated by staff at the Health Research Board (HRB) on behalf of
the Department of Health and Children. The number of drug treatment services
participating in the NDTRS continues to increase (Standard Table TDI 34). Although
treatment is provided within the Irish Prison Service, it was only in 2009 that
counsellors working in the prison service began to return information to the NDTRS.
The Central Treatment List (CTL) was established under Statutory Instrument No 225
following the Report of the Methadone Treatment Services Review Group 1998
(Methadone Treatment Services Review Group 1998). This list is administered by the
Drug Treatment Centre Board on behalf of the HSE and is a complete register of all
patients receiving methadone (for treatment of opiate misuse) in Ireland and provides
all data on methadone treatment nationally.
The National Drug-Related Deaths Index (NDRDI), established in 2005, is an
epidemiological database which records cases of death by drugs poisoning, and
deaths among drug users in Ireland, extending back to 1998. The NDRDI also records
data on alcohol-related deaths, deaths among alcoholics, and deaths from alcoholrelated diseases, extending back to 2004.
The Research Outcome Study in Ireland (ROSIE) was the first prospective study of
treatment outcomes for opiate users to be conducted in Ireland. The objective was to
evaluate the effectiveness of treatment and other intervention strategies for opiate use.
The study recruited 404 opiate users entering treatment between September 2003 and
June 2004. Three treatment modalities, provided through both inpatient and outpatient
settings, were the focus of attention – methadone maintenance, structured
detoxification, and abstinence-based treatment programmes. In addition, a sub-sample
of individuals was recruited from needle exchange interventions. Participants were
interviewed at treatment intake, or as soon as possible thereafter, and again at 6
months, 12 months and 3 years after the baseline interview. Data were collected by
means of a structured interview. The interview instrument contained a comprehensive
set of outcome measures detailing the social and psychological characteristics of the
59
cohort, and a range of treatment process factors in relation to treatment outcomes.
Between September 2006 and October 2008 seven papers in the ROSIE Findings
series, concentrating on particular aspects of the study, were published; in June 2009 a
report on outcomes at 1-year and 3 years for the whole population and the ‘per
protocol’ population, i.e. participants who completed all three interviews, was published
(Comiskey, Catherine M, et al. 2009). }. In 2010 six further papers reporting on the data
were published including analyses of the effects of treatment settings, treatment
pathways and use of additional drugs on treatment outcomes for opiate users.
5.2
General description, availability and quality assurance
In Ireland there is a range of addiction services incorporating education and prevention,
harm reduction, treatment, stabilisation, rehabilitation and aftercare support. Many of
the services are statutory, provided by the HSE, but a proportion are provided through
voluntary organisations, frequently funded by the HSE. There are a number of private
services which are fee-based or religious. There is no national database which can
provide the complete number of services and what treatment they provide. A website,
drugs.ie, which provides a search engine on information on HSE services, is currently
being revised (see Section 5.4.3 below).
The number of services participating in the NDTRS are reported below (see Table
5.2.1). The increase in the number participating reflects both an increase in drug
treatment services and also the successful efforts to improve participation in the
NDTRS. In 2009, data were provided by 349 treatment services to the NDTRS, an
increase of 88 since 2004. Most of the services participating are in outpatient settings.
The number of low threshold services participating increased in 2009 owing, again, to
the active recruitment by NDTRS staff, supported by LDTFs who fund many of these
projects.
Table 5.2.1 Number of services participating in NDTRS by type of service provider, 2004–2009
2004
2005
2006
2007
2008
2009
All services
261
269
238
288
316
349
Outpatient
144
146
146
173
209
212
Inpatient
19
21
23
27
32
34
Low threshold
3
3
3
5
9
27
General practitioner
95
99
66
83
66
76
Source: Unpublished data, NDTRS
In 2010, 276 GPs were providing methadone treatment under the MTP (unpublished
data, CTL). The ICGP is responsible for auditing GPs and undertakes random audits
of GPs involved in methadone treatment (Irish College of General Practitioners 2010).
Community pharmacists are also involved in the dispensing of methadone, thus
ensuring that a large number of opiate dependent persons may be treated in their own
local areas.
To help ensure drug treatment and rehabilitation outcomes are achieved and to
maintain a high standard of client safety, the National Drugs Strategy (interim) 2009–
2016 (NDS) calls for the introduction of ‘a clinical and organisational governance
framework for all treatment and rehabilitation services in Ireland’ (Department of
Community Rural and Gaeltacht Affairs 2009): (Action 45). Since 2010 the Progression
Routes Initiative (PRI), in collaboration with the HSE, has been introducing the UKbased Quality Standards in Alcohol and Drugs Services (QuADS) to service providers
in Ireland. See ‘Quality Standards in Alcohol and Drugs Services (QuADS)’ in Section
5.4.1 below for further information about this project.
5.3
Strategy/policy
HSE plan for drug-related services in 2011
60
The HSE National Service Plan 2011 set out the agency’s plan in the drugs and alcohol
area for 2011 (Health Service Executive 2011b). A priority for the HSE Social Inclusion
Services, which include addiction services, was to ‘continue to address the health
impacts of addiction and/or substance misuse’. The Social Inclusion Services also
prioritised actions to enhance the health and well-being of other vulnerable groups,
including the homeless, Travellers, ethnic minorities and members of the lesbian, gay,
bisexual and transgender (LGBT) communities. ‘Deliverable outputs’ for 2011 are listed
in Table 5.3.1.
Table 5.3.1
Deliverable outputs for drug-related services in 2011
Key result area
Deliverable outputs 2011
National Drugs
Recruitment of clinical directors of addiction services
Strategy (NDS)
completed in each of the four regions.
2009–2016
Implementation of Phase 1 of interagency rehabilitation
programmes in each of the four regions.
Learning from reports implemented, including hepatitis C
and intravenous drug users and methadone protocol
Pharmacy-located harm reduction/needle exchange
services implemented throughout the country in each of the
four regions
Alcohol public education/awareness campaign developed
and launched
Screening and brief interventions available in emergency
departments and primary care services (Phase 1)
National Addiction Training framework in place for staff
(Phase 1)
National
Protocols signposting referral pathways developed between
Homelessness
specialist addiction/ homeless/Traveller services and
Strategy
mental health and primary care services
All-Ireland Traveller Screening programmes targeting vulnerable groups [among
Health Study
the Traveller population] devised and implemented
National
Emergency multi-lingual aid toolkits for staff and
Intercultural Health
intercultural health guide implemented
Strategy
Translation/interpreting toolkit for staff in line with Patient
Charter implemented
LGBT Framework
Good practice guiding principles developed to support
LGBT communities in equitable access and use of health
services
Target completion
Q3
Q3
Q3
Q3
Q2
Q4
Q3
Q4
Q4
Q3
Q2
Q4
Source: (Health Service Executive 2011b), pp. 49–50
With regard to drug treatment, comparison with the 2010 plan indicates that the HSE
has sought to maintain similar overall levels of activity and performance in 2011 while
increasing service provision in the South and West regions. A briefing note to the
incoming Minister for Health (Social Inclusion Unit and Department of Health and
Children 2011) explained the shift in emphasis as being due to the ‘unacceptable
waiting times in some locations, mainly in the Midlands, East and South as well as in a
small number of treatment centres in Dublin’.
Methadone treatment – The target for 2011 has been to increase the total number of
clients in methadone treatment outside prisons by 2.6%, from 8,278 to 8,500, and the
number in treatment in prisons by three, from 497 to 500. While the number of clients in
methadone treatment in the Dublin/Mid-Leinster (DML) and Dublin/North-East (DNE)
regions will rise by 1% (from 7,861 to 7,950), in the South Region the number is set to
increase by 47% (from 187 to 275), and in the West Region by 19.6% (from 230 to
275).
Treatment of substance misusers over 18 years following assessment – In 2010 the
target of ensuring that 100% of substance misusers over 18 years started treatment
within one calendar month of assessment was not achieved: in the DML and DNE
regions only 70.6% and 71.1% respectively entered treatment within the month, while in
the South and West regions the proportions were 98.5% and 97.7% respectively. In
2011 the HSE will again try to reach the 100% target.
61
The expected 100% target for 2011 was estimated to be 2% lower than in 2010, with
the total number of substance misusers over 18 years who would have commenced
treatment following assessment expected to drop from 1,380 to 1,350. In the DML and
DNE regions the number was expected to decline by 67% (from 870 to 520), while in
the South and West regions it was expected to increase by 63% (from 510 to 830).
Treatment of substance misusers under 18 years following assessment – In 2010 the
total number of substance misusers under 18 years who commenced treatment
following assessment exceeded the target of 115 by 18% (n=136). While the DML,
DNE and South regions all came in on or under target, the West Region exceeded its
target by 46% (65/30).
The 2010 target of ensuring that 100% of substance misusers under 18 years
commenced treatment within two weeks of assessment was met in the DML and DNE
regions, but was not achieved in the South and West regions. In 2011 the HSE again
set the target at 100% for all four HSE regions.
The 2011 plan also set out the HSE’s priorities and actions with regard to delivering its
statutory services in the areas of children in care, after care and youth homelessness,
and also with regard to maintaining and developing family support services and
strengthening the provision of aftercare services. Specifically in relation to substance
abuse, the service plan stated that an ‘analysis of addiction services for children
nationwide based on best practice’ would be completed in the fourth quarter of 2011.
This action was in response to a recommendation in the Report of the Commission to
Inquire into Child Abuse (the Ryan Report), on the provision of counselling and
educational services for children, which called on the HSE and the drugs task forces to
establish addiction services for children nationwide based on best practice by June
2011 (Ryan 2009)
New programme for government
The new programme for government, Government for National Recovery 2011–2016
(Fine Gael and the Labour Party 2011) contains a number of actions related to drugs
policy. The action directly related to drug treatment was to target resources to
increasing the number of rehabilitation places across the country where it is needed
most. In 2007, the HSE Working Group on residential treatment and rehabilitation had
reported a shortfall of 104 inpatient detoxification places and 252.5 rehabilitation places
(Corrigan and O'Gorman 2007). Action 32 of the NDS published in 2009 called for an
integrated national treatment and rehabilitation service for all substance users.
5.4
Treatment systems
5.4.1
Organisation and quality assurance
The National Drugs Rehabilitation Framework
In line with the recommendations outlined in the report of the Working Group on Drugs
Rehabilitation (Department of Tourism Sport and Recreation 2001), a National Drugs
Rehabilitation Framework (NDRF) has been published (Doyle and Ivanovic 2010).
Approved by the National Drugs Rehabilitation Implementation Committee (NDRIC),
this NDRF has been constructed to enhance the provision of rehabilitation services to
current and former drug users by creating integrated care pathways (ICPs) with the cooperation of different service providers.
It is recognised that service users may present with diverse needs, including treatment,
education, vocational training, employment support and accommodation, and that no
single agency can cater for all possible needs. An individual care plan will be
developed for each service user, and will be delivered by a multi-disciplinary team
comprising the range of necessary disciplines and skills drawn from a variety of service
providers. Where a service user has complex and multi-faceted needs, a more
intensive case management approach may be used.
62
According to the authors of the NDRF, ‘The provision of rehabilitation pathways is a
shared responsibility of the education, training and employment sectors alongside the
health, welfare and housing sector, non-governmental organizations, communities,
families and the individual themselves.’ (p. 7)
The ICP will comprise four steps, which will be linked to the four-tier model of service
provision:
 Initial contact (Tier 1 services): Screening and referral, using a brief intervention
screening instrument.
 Initial assessment and identification of appropriate service (Tier 2 services
upwards): Matching person to service – the aim is to determine the seriousness
and urgency of the drug/alcohol problem.
 Comprehensive assessment – key working and care planning (Tier 3 services
upwards): Matching services to the person, i.e. identifying appropriate services for
service users with more complex needs. Following the comprehensive assessment,
a case manager will be identified, who will support the individual on their
rehabilitation pathway.
 Implementation of the care plan to support an individual rehabilitation pathway.
Services drawn from the four-tier model of service provision will be characterised by
the following attributes:
 Settings may include general healthcare, structured drug treatment, communitybased specialist addiction services, and residential detoxification and treatment
followed by supported step-down accommodation as part of aftercare.
 Services may include information and advice, brief interventions, methadone
treatment, harm reduction and therapeutic interventions.
 Target groups may range from those experimenting with drugs to those with drugrelated problems and dependence.
The development of a competent workforce in the addiction services will be supported
and maintained through the development and implementation of a quality standard
framework. See ‘Quality Standards in Alcohol and Drugs Services (QuADS)’ later in
this section for further information on the introduction of these standards.
The NDRIC is currently piloting the ICP model at regional and local levels, with a view
to informing the development of the protocols (National Drugs Rehabilitation
Implementation Committee 2010). Three drugs task force sites – North Inner City
LDTF, Blanchardstown LDTF and North East RDTF – have been selected to participate
in phase 1 of the pilot process. The objectives of the pilot projects are to:
 support the implementation of the NDRF and the ICP model,
 build awareness and knowledge of the NDRF among key stakeholders,
 identify progress in implementation,
 identify gaps in services and drivers/obstacles in respect of implementation,
 assess the initial impact of the NDRF, and
 help to clarify roles and inform implementation of the NDRF.
Review of the methadone treatment protocol (MTP)
The results of the first external review of the MTP were published on 20 December
2010 (Farrell, Michael and Barry 2010). The HSE commissioned Michael Farrell,
Professor of Addiction Psychiatry at Kings College London, to conduct the review,
assisted by Joe Barry, Professor of Population Health Medicine at Trinity College
Dublin. This is the second review of the protocol; the Methadone Prescribing
Implementation Committee carried out an internal review in 2005 (Methadone
Prescribing Implementation Committee 2005).
The review was informed by 69 written submissions and the conclusions of 38 oral
hearings with stakeholders on the impact of the protocol. The authors state that the
original protocol achieved its aims, especially in relation to improving both poor
63
prescribing and the quality of independent practitioner practice. In line with their terms
of reference, the reviewers made recommendations with regard to the following
themes:
Maximising treatment provision and reviewing the efficacy of referral pathways – The
report calls for improved access to detoxification treatment, but in conjunction with the
necessary psychosocial supports. The inclusion of buprenorphine/naloxone treatment
in the methadone regulations is recommended, to which end the review is entitled The
introduction of the opioid treatment protocol. The spread of the drug problem outside
Dublin is noted, with a recommendation for the development of a rural service model as
a priority. The authors support the concept of an ICP in order to promote integration
and sharing between the different treatment agencies to provide a more flexible,
innovative and responsive service.
Clinical governance and audit – The review recommends that the lines of reporting
within the drug treatment services be reviewed. It also recommends that the current
audit process be expanded. Although benzodiazepine prescribing was not directly
within the terms of reference of the review, it is mentioned in this section. The authors
state that ‘there was a need for a concerted approach to achieving tighter and more
responsible prescribing of benzodiazepines’ (p. 27). They call for the recommendations
of the 2002 report of the Benzodiazepine Committee (The Benzodiazepine Committee
2002) to be implemented.
Enrolment and training of GPs and the GP co-ordinator role – The success of involving
more GPs in Level 1 training is recognised, with the expectation that in the near future
all trainees completing GP training will meet the criteria for Level 1. However, the report
states that there is a need for more Level 2 GPs and increased movement of stable
clients from Level 2 to Level 1 GPs within a specified timeframe. It recommends that
the model of GP-nurse liaison practitioner be developed and the role of the GP coordinator be revised.
Urine testing – The authors note that there is a lot of criticism from some of the
contributors about the appropriateness and efficacy of urine testing in the drug
services. It is felt that practices vary between doctors and services, and the
considerable amount of time and resources it takes could be used more productively
for the clients. The existing regime of testing is considered to capture only very
frequent drug use, which is often clinically obvious. Research is quoted which states
that random testing, and testing based on reasonable grounds for concern, could
reduce the number of tests needed and make them more meaningful. In the review,
new improvements are discussed, for example saliva testing, which could eliminate the
need for supervision (except where there is a legal requirement) and be more userfriendly.
Prescribing of methadone in Garda (police) stations –The review states that there are
no specific standards, guidelines or recording mechanisms around prescribing
methadone in Garda stations. Along with a review of procedures for medical
assessment of people in custody, it recommends that guidelines for prescribing
methadone in this setting be developed and implemented urgently. It also recommends
that doctors prescribing methadone in Garda stations should have access to
information on the CTL, especially out of hours.
Data collection, collation and analysis – The review recommends the inclusion of an
annual outcome monitoring process with the data collection tools. It also suggests
linking the collected data with the Health Research Board’s national surveillance data
on drug treatment, which would result in information on pathways and long-term
outcomes of drug users.
64
Involving services users in service planning
Action 42 of the NDS identifies the need to further involve the users of drug treatment
services, ‘both as an essential part of clinical governance procedures and service
planning’ (Department of Community Rural and Gaeltacht Affairs 2009)(para. 4.79).
The issues to be considered when involving service users are highlighted in a
qualitative study of service user involvement in a Dublin-based methadone
maintenance service (King, Aoibhinn 2011).
Completed in mid-2008, this study was based on in-depth semi-structured interviews
with eight providers from the service, three drugs task force co-ordinators and the coordinator of the drug-user group, and eight service users attending different clinics
across the broad geographical area in which the service operated. The author,
Aoibhínn King, in the School of Social Work and Social Policy, Trinity College Dublin,
identifies issues around five themes:
Purpose of the service – There were conflicting views about the purpose. Service users
were clear that the purpose was to contribute to a reduction in the difficulties they
experienced through drug use and to the stabilisation and normalisation of their lives.
Service providers were more ambivalent: while many saw abstinence as the final goal,
they claimed that harm reduction and improved quality of life were the actual outcomes.
Understanding of user involvement – While there was overall consensus that user
involvement was both progressive and desirable, and increased the effectiveness of
the service, in reality, service users’ experience was that the system did not engage
with them: ‘I’m not involved at all, like they haven’t asked me to do anything, just come
up and get me methadone.’
Determining own care – Respondents generally endorsed the principle that service
users have valuable knowledge and experience that can help in planning and
delivering their care programme, but they were almost unanimous in stating that, in
practice, service users played little or no part in determining their own treatment.
Moreover, there was a prevailing view that both service users and service providers
gave higher priority to issues around methadone maintenance than to addressing the
issues which impacted on the individual’s life and influenced their drug use.
Involvement in service evaluation, planning and development – Involvement was
perceived as largely symbolic. Several obstacles were identified, including resource
constraints, organisational and national protocols and procedures, unrealistic
expectations on the part of service users, disillusionment and fear of criticism on the
part of service providers. The author also noted, ‘the culture within services served as
the most significant barrier to meaningful collaboration’.
Operational system and interactions between service users and service providers –
The author found that the staff attitudes common under the ‘old system’ of treatment
still pervaded the culture in treatment services and was the main impediment to the
active engagement of service users. Staff tended to define service users in negative
stereotypical terms, and service users, in turn, characterised their relationship with
treatment systems primarily in terms of fear, rather than terms of equality or mutuality.
King describes the explicit acknowledgement of the imbalance of knowledge and power
between provider and user as ‘remarkably stark’. While the service studied was
nominally imbued with the harm reduction ethos, the author found that the underlying
philosophy of the old drug treatment system had not shifted to any great extent. To
bring the treatment service into line with harm reduction philosophy, King concludes
that much more is needed than simply including abstract statements of principle in
official policy documents: ‘It may be that what is needed is a more explicit and
committed approach which incorporates the education and training of all involved in the
delivery of treatment services for illicit drug users, if the situation identified here is not
to persist.’
65
Quality Standards in Alcohol and Drugs Services (QuADS)
The national standards for drug and alcohol treatment services agreed by the HSE are
the Quality in Alcohol and Drug Services (QuADS) organisational standards, originally
developed in the United Kingdom.8 In 2010 the Progression Routes Initiative (PRI)
supported 30 services, and took on another 70 services in local and regional drugs task
force areas in 2011, to become ‘QuADS compliant’. The process occurs in two phases.
Self-review – Each organisation works through the QuADS framework, reviewing their
policies and procedures against template policies provided. The following supports are
provided for this self-review and organisational change process:
 A ‘policy library’ is available on line. It contains more than 75 template policies,
covering governance, human resources, service provision policies, service-userrelated policies, and case management and care planning. These policies have
been extensively researched and had editorial input from industry leaders from the
health and commercial sectors. Participants are advised to adapt these policies to
their own needs through an internal consultation process involving staff and service
users.
 Service-specific facilitation and policy development is available on request. It is an
effective way of engaging staff and management in the development of
policies. Service-specific training modules are also available.
 Directors seminars for all participating organisations are held approximately every
quarter to facilitate interagency best-practice learning.
Peer review – After completion of the self-review phase and the integration of quality
standards and procedures into all aspects of operations, an organisation or group may
request a peer review. Peer review is a relatively new way of promoting and supporting
organisational and sectoral development. It has been used within therapeutic
communities across Europe and also in the youth services sector. In the QuADS
context it involves two organisations from within the QuADS network auditing and
evaluating the work of another organisation against a standardised framework, using a
specially developed IT system. Over two days these reviewers meet with service users,
staff and managers and complete a policy and file audit. The reviewers draft a
comprehensive report that assists the organisation under review to further improve its
policies, systems and procedures. The reviewers also present an overview of their
findings to a representative group of service users, staff and management, in order to
ensure a cohesive and transparent process and to contribute to collective ownership of
the QuADS approach.
5.4.2
Availability and diversification of treatment
Merchants Quay Ireland (MQI) annual review, 2010
According to its annual review for 2010, MQI’s open-access drug services are often the
first place to which drug users turn for help (Merchants Quay Ireland 2011) The review
is particularly useful, therefore, in providing information not fully reflected in the
treatment figures recorded by the NDTRS.
MQI’s needle-exchange service recorded just under 25,000 client visits in 2010, a 20%
decrease on the numbers using the service in 2009. MQI attributed most of this decline
to a ‘heroin drought’, which the review stated began at the end of October 2010 and
continued into the early months of 2011. While the number of needle exchanges in
January 2010 was 2,650, in December 2010, at the height of the drought, this number
dropped to 850. The total number of service users was 4,308, an increase of 5%, and a
total of 575 new injectors presented. MQI commented, ‘The figures here serve as a
reminder that heroin use remains at very high levels and that significant numbers of
new people are beginning to use heroin every year.’ (p. 10)
8
For more information on QuADS, see the Report of the HSE Working Group examining Quality & Standards for
Addiction Services Corrigan, D. and O'Gorman, A. (2007). Report of the HSE Working Group on Residential Treatment
& Rehabilitation (Substance Users). pp. 62. Health Service Executive, Dublin. Available at
www.drugsandalcohol.ie/6382/
66
The report highlighted a substantial increase in demand for homelessness services.
The number of health care interventions provided increased by 15%, from 3,216 in
2009 to 3,685 in 2010.
2010 saw the development of new initiatives at MQI. These included the Extended Day
Service developed in association with Focus Ireland, the New Communities Support
Service, Midlands Traveller Specific Drugs Project, Aftercare Housing in conjunction
with Respond Housing Association, Drug Free Day Programme and Easy Access
Education for Homeless People
In 2010 MQI again won the tender to deliver a national counselling service for prisoners
with drug and alcohol problems in 13 of the state’s 14 prisons. In 2010 the service
provided in excess of 13,000 counselling hours; the 23 counsellors each carried an
average caseload of more than 550 prisoners.
In 2010 MQI continued to deliver the Midlands Family Support and Community Harm
Reduction Service. The Family Support Service provided services to 237 new clients;
the harm reduction service provided needle exchange services to an average of 62
clients per month, providing 174 interventions in the form of advice and support and an
average of 124 needle exchanges. In September 2010 a rehabilitation and aftercare
service was also established in the midlands and by year-end this had been accessed
by 55 clients.
Table 5.4.2.1 Types of service offered by MQI, the numbers of people accessing them, and the
outcomes, 2010
Service
Type of intervention
No. of participants
Outcomes
Needle-exchange and Promotes safer injecting
4,308 used needle–
health-promotion
techniques
exchange services, of
services
HIV and hepatitis prevention
whom 575 were new
Safe sex advice
clients
Information on overdose
1,617 safer injecting
–
Early referral to drug treatment
workshops
services
Stabilisation services
Methadone substitution
Supportive day programmes
Gateway programme
Counselling
19
–
78 (monthly average)
–
–
–
–
–
Settlement service
Assists service users to find,
access and sustain long-term
appropriate accommodation
74 (quarterly average)
45 resettled
Reintegration
programmes
Access to transitional
accommodation after completing
residential drug treatment
Group and one-to-one therapeutic
sessions
Average of 3 people in
3-bed house throughout
the year
–
Training and work
programmes
FÁS Community Employment
scheme
90
Of the 26 who completed FÁS
placement at MQI, 31% secured
permanent employment or moved
to further education
High Park
17-week, drug-free residential
programme including individual
counselling, group therapy,
educational groups, work
assignments and recreational
activities
62 (of whom 13 were
admitted for
detoxification)
10 completed detox and 22
completed the full programme
St Francis Farm
Therapeutic facility offering a 6month programme
34
11 completed the full programme
–
Source: (Merchants Quay Ireland 2011)
67
Community detoxification pilot programme for methadone and benzodiazepines
A pilot programme for community detoxification, led by PRI, began in north inner-city
Dublin in 2008 and was evaluated in 2009 (Alcohol and Drug Research Unit 2008)
(Irish Focal Point 2010). This pilot has now been expanded outside Dublin. In this
phase of the pilot, two separate detoxification protocols are planned, one for
methadone and one for benzodiazepines.
The pilot is overseen by an expert committee, with representatives from PRI, the HSE,
user groups and other relevant stakeholders. The pathways to treatment, brokerage,
and the support offered and other processes remain the same, but the individual
protocols will give more in-depth and tailored information for each substance, such as
entry and exit criteria, and detoxification schedules.
The protocols are aimed at doctors and key workers who wish to support a person
through the process of detoxification in the community. The protocols outline the
minimum medical and psycho-social supports necessary, covering medical
detoxification, interagency holistic care planning and relapse prevention. This phase is
expected to begin in the autumn of 2011. It will be evaluated over the next two years
using quantitative and qualitative methods.
Regulating administration of suboxone
The Department of Health and Children commissioned an independent agency to
evaluate the suboxone feasibility study (see Chapter 5.3.2 of National Report 2010)
(Irish Focal Point 2010). Completed in April 2011 but not yet published, this evaluation
is expected to make recommendations to the expert group overseeing the study
regarding the circumstances and client groups for which the drug is most suitable and
the appropriate regulatory framework (Social Inclusion Unit and Department of Health
and Children 2011).
National Addiction Training Programme (NATP)
The briefing to the incoming Minister for Health, released in March 2011, informs the
Minister that cognitive behaviour coping skills (CBCS) training, rehabilitation training
and brief interventions, particularly in regard to overdose and alcohol screening, are
being provided through the NATP. The briefing note states:
The brief intervention model has been piloted in three hospitals in 2010 and it is
intended to develop this further in 2011 with training supported via the NATP. In this
expansion the key objective of providing a joint drug/alcohol brief intervention will be
explored. This will support the need to analytically examine those attending Emergency
Departments with addiction issues via the HIPE data base. The initial meeting of the
reconstituted Steering Group took place on 7th February [2011] with the next meeting
scheduled for the 14th March.’ (Social Inclusion Unit and Department of Health and
Children 2011) (Document 17: Section 2.3)
Keltoi residential rehabilitation programme
Part of the rehabilitation services available in the Dublin 12 Drugs Task Force area,
Keltoi, based in St Mary’s Hospital, Dublin 20, offers a residential therapeutic
rehabilitation programme for problem opiate users. It emphasises occupational work,
with a strong focus on after-care and living drug-free. This study has been published,
reporting on follow-up interviews with clients who attended the Keltoi programme
between September 2002 and July 2004 (White, et al. 2011). It was done as part of a
wider evaluation of the programme, which has already been published (Sweeney, et al.
2007).
The study aim was to evaluate the effectiveness of the Keltoi programme in helping
participants to remain drug-free. During the evaluation period, 149 clients had entered
Keltoi, 94 of these had participated in the original evaluation, and 80 participated in the
follow-up interview, which was based on the Maudsley addiction profile (MAP). The
interviews started in May 2004 and finished in July 2009. The average time between
discharge and follow-up interview was 1.9 years (range 1.2 to 3.0 years). Two
68
participants in the original evaluation were known to have died before their follow-up
interview took place, giving a mortality rate of 2.1% for the 94 participants. There was
no control group.
Half (51.3%) of the interviewees self-reported as fully abstinent (defined as abstinent
from all substances including alcohol and prescription substitution drugs) in the 30 days
before the interview. Most (88.1%) were still in contact with some type of drug
treatment service. Those who were abstinent reported higher levels of well-being than
those who reported that they were not abstinent.
In the 30 days before the interview:
 five (6.3%) interviewees reported injecting;
 a lower proportion of those who were abstinent (3.8%) reported suicidal thoughts
compared to the proportion of those who were not abstinent (18.8%);
 over two thirds (77.5%) of those interviewed reported no criminal activities; and
 half (50.0%) reported having undertaken paid employment.
The authors recognised that self-reported abstinence was a limitation, but they
concluded that the evidence showed that self-reporting was reasonably reliable among
this population as there were no negative consequences for the interviewees. Because
of the methodology used it was not appropriate to undertake statistical analysis of the
data looking for factors which might be associated with abstinence. For the same
reason, the authors stated that they were ‘wary of direct comparisons with the majority
of current international literature’ (p. 358).
Compared to the completion rate among the abstinence cohort in the ROSIE study
(66%) (Cox, et al. 2007), the rate of completion in Keltoi was higher (77%). The
outcomes of the Keltoi also compare favourably with another Irish study done by Smyth
and colleagues (Smyth, et al. 2005), which described the follow-up outcomes for those
with opiate dependence who had received inpatient treatment. The Keltoi study
participants reported abstinent rates of 51% at follow-up, compared to 23% in the
Smyth study (Smyth, et al. 2005).
The authors concluded that there were large gaps in outcome-based evaluations for
treatment programmes in Ireland and recommended the introduction of a health
outcomes monitoring system. They also concluded that the evidence from their study
and others in this area showed that many of those who enter residential treatment do
not have successful outcomes. It is important to find out what works and what doesn’t
work for different people.
Coolmine Therapeutic Community (CTC)
In August 2010 CTC started a longitudinal research study in collaboration with Paula
Mayock, Senior Researcher/Lecturer in Youth Research, Social Work, and Social
Policy, Trinity College Dublin, and the National Health Information Systems Unit of the
HRB (personal communication, Anne Marie Carew, HRB, August 2011). The aims of
the study are to:
 collect baseline data on drug use, health and behavioural status of participants as
they enter and progress through primary treatment and aftercare in CTC,
 follow up participants over time including after leaving the CTC programme, and
 compare CTC client outcomes with outcomes recorded in other national outcome
studies, e.g. ROSIE.
The study will use both quantitative and qualitative methodologies and it is estimated
that up to 30 people will participate in the study. Each participant’s progress will be
followed up every six months during their treatment (i.e. three times) and then 18
months after discharge. The quantitative data will be obtained from Treatment
Outcome Profile and routine data collected through the NDTRS. The qualitative data,
collected through one-to-one interviews with participants, will help reveal their reasons
for choosing treatment in a therapeutic community and their perceived progress over
69
time. The experiences of those who drop out of the programme will also be recorded
and analysed. There are no preliminary results available at this time.
5.4.3
Access to treatment
Methadone treatment in Ireland
Table 5.4.3.1 shows the number of continuous care clients attending methadone
treatment, as recorded in the CTL (see also Standard Table 24). The figures have
steadily increased, from 3,681 in 1998 to 8,727 in 2010. Over the past five years,
approximately 800 new clients have started methadone treatment each year, an
increase of roughly 7.5% per annum. It is also reported that some 450 people
successfully complete their treatment episode each year (Shortall 2011, 11 May).
Table 5.4.3.1 Number of continuous care clients attending methadone treatment (on 31 December
each year), CTL, 1998– 2010
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
3681 4339 4973 5610 5954 6444 6925 7262 7620 7942 8266 8551 8727
Source: (Farrell, Michael and Barry 2010)
The recently published review of the methadone protocol in Ireland (Farrell, Michael
and Barry 2010) provides an overview of data on methadone treatment in Ireland over
the past decade. Although the number of clients attending GPs for methadone
treatment has increased, the proportion attending clinics for treatment has remained
almost the same, 65% in 2002 compared to 63% in 2009. What has changed is the
proportion of clients attending Level 1 GPs, up from 14% in 2002 to 18% in 2009.
Currently, Level 1 GPs are qualified to treat up to 15 stabilised clients in their practice.
The review also provides a snapshot of waiting times for methadone treatment in
clinics as of 31 July 2010. Of the 63 clinics represented, over three quarters (78%)
reported that less than 10 people were on their waiting lists. Thirty-five clinics (56%)
reported that their average waiting time was less than one month. The longest average
waiting time was reported to be 13.5 months (at a Dublin clinic). The highest number of
clients on waiting lists was in the Midlands (over 40 people) and this area also reported
some of the highest average waiting times (between 5.6 and 10.5 months). The
spread of the heroin problem outside Dublin has been well documented in recent years
(Carew, et al. 2009).
Data from the NDRDI show the proportion of those who died while registered on the
CTL. The proportion remained low over the 10-year period, rarely rising above 1%
(Table 5.4.3.2). However, these figures do not include those who died from illicit/street
methadone or those who may have died from drug-related causes shortly after leaving
methadone treatment (see Standard Table 24).
Table 5.4.3.2 Proportion of CTL registered patients who died, NDRDI, 1998–2007
1998
1999
2000
2001
2002
2003
2004
2005
Total number of
3681
4339
4973
5610
5954
6444
6925
7262
CTL cases*
Total number of
39
49
39
47
66
58
66
72
CTL deaths
Proportion of
deaths among
(1.06) (1.13) (0.78) (0.84) (1.11)
(0.9)
(0.95) (0.99)
those registered
on CTL (%)
2006
7620
2007
7942
78
62
(1.02)
(0.78)
*unpublished data from the Central Treatment List
Source: (Farrell, Michael and Barry 2010)
In order to address waiting times for access to methadone maintenance treatment,
especially in rural areas outside Dublin, the HSE has funded 13 new clinics throughout
the country (Limerick city, Cork city, Tralee, Wexford, Gorey, Carlow/Kilkenny,
Waterford, Drogheda and Dundalk) (Social Inclusion Unit and Department of Health
and Children 2011).
70
Online access to treatment and rehabilitation services
According to the briefing paper prepared for the incoming Minister for Health, released
in March 2011, the HSE Social Inclusion Services, in partnership with drugs.ie,9 is
currently developing an interactive online care pathway planning tool encompassing a
searchable services directory that gives extensive information on each listed drug and
alcohol service provider. The briefing paper states that it is envisaged that this online
service will be a starting point both for people wishing to access treatment and
rehabilitation (and harm reduction), and for professionals wishing to locate
complementary and follow-on services for existing clients to facilitate a continuum of
care approach (Social Inclusion Unit and Department of Health and Children 2011).
5.5
Characteristics of treated clients (TDI data included)
Treated opiate users
Researchers have analysed subsets of participants and data from the longitudinal
ROSIE study (Comiskey, Catherine M, et al. 2009) and published six new papers. The
articles cover the effects of treatment settings, treatment pathways and use of
additional drugs on treatment outcomes for opiate users.
Impact of treatment setting (Comiskey, Catherine and Cox 2010)
In this analysis, 215 cases enrolled in different methadone treatment programmes were
included – community-based clinics (22%), GPs (25%) and HSE clinics (53%). The
analysis found that methadone treatment was effective in reducing drug use regardless
of treatment setting. Further analysis using ANOVA and logistic regression found that
setting was not significant when predicting improvement of physical symptoms. The
authors state that opiate users should be enrolled in settings that meet their individual
needs, taking into account such factors as heroin use at intake and physical symptoms.
Longitudinal outcomes for treated opiate use and ancillary medical and social services
(Comiskey, Catherine and Stapleton 2010a)
For this paper, 73% of the participants in ROSIE were included (at 1- and 3-year
interviews). Outcomes at the 3-year follow-up were assessed using an adapted
Maudsley Addiction Profile (MAP), which measured drug, crime, physical and
psychological health. The study found three different outcome groups:
 15% were not in treatment and were drug free,
 70% were in treatment, and
 15% were not in treatment and were using drugs.
The number of additional services accessed by participants was analysed, rather than
the original treatment setting through which the client had entered. Accessing
counselling prior to recruitment to treatment, accessing residential treatment in the first
year and accessing group work were all significantly associated with the ‘not in
treatment and drug-free’ group. The authors acknowledge that one of the limitations
was that the outcome status of all 404 participants was not known. However, they
state that the findings are important, especially in the current difficult economic climate
when service providers are under pressure to cut the cost of providing services which
may in the long term be less cost-effective.
Treatment pathways and longitudinal outcomes for opiate users (Comiskey, Catherine
and Stapleton 2010b)
As the three outcome groups described in the previous study were very distinct, the
authors undertook further analysis which reveals that there were no differences in
characteristics between the three different groups of participants at intake, even
between those who were classified as doing well (drug free and not in treatment) and
the other two groups. However, the results do show that those who were doing well at
the 3-year follow-up had also shown improvements, especially in physical and mental
9
Drugs.ie is an independent website managed by Crosscare’s Drug and Alcohol Programme and funded by the HSE.
71
health outcomes, at the first-year follow-up. The authors recommend that future
studies should focus on modelling outcomes and pathways instead of treatment
setting. They suggest that this would allow greater understanding of how and why
treatment works.
Anxiety and depression among opiate users (Stapleton, Robert and Comiskey 2011)
The aim of this study was to examine differences in states of anxiety and depression,
using the results from the MAP at 1-year and 3-year follow-up. The study modelled
usage of different drugs against different anxiety or depression-related symptoms. At
one year, use of heroin was significantly associated with certain symptoms of anxiety:
feeling fearful, and feelings of terror and panic; it was also associated with all the
symptoms of depression. Cocaine and cannabis use were also significantly associated
with all the symptoms of depression. The results for non-prescribed methadone and
benzodiazepines showed more variation: non-prescribed methadone was significantly
associated with all the symptoms measured, but for some symptoms it was a predictor,
e.g. more likely to feel hopeless about the future, while for others it appeared to be a
protective factor, e.g. less likely to have suicidal thoughts.
There was not a clear pattern of anxiety symptoms among participants at the 3-year
follow-up, with some drugs having an effect on symptoms at one year but not at three
years, and vice versa. This lack of a clear pattern made it difficult to draw any definitive
conclusions. However, the authors feel that there is evidence of an association at three
years between drug use and anxiety symptoms of feeling terror or panic. For symptoms
of depression, the results were more consistent over the three years, with the risk of
depressive symptoms being higher particularly for heroin and cocaine users.
One of the limitations of the study was that it did not record the mental-health history of
the participants before enrolling in the study. As a result, it is not possible to say
whether the depressive symptoms were the result of drug use or was the drug use a
response to depressive symptoms. The authors conclude that there is enough
evidence to show that drug treatment service providers should consider these mentalhealth issues, and this, in turn, may improve treatment outcomes for the clients.
Treated opiate users: alcohol use and treatment outcomes (Stapleton, RD and
Comiskey 2010)
The aim of this analysis was to examine the frequency and quantity of alcohol use
among opiate users at entry to treatment and at follow-up, to establish ‘whether the
success rate of a program may be, in part, related to the alcohol using habits of the
client’. Data relating to 242 of the original ROSIE participants were classified according
to their alcohol usage: (1) abstainers (had not drunk in the past 90 days); (2) medium
drinkers (consumed up to 70g [men] or 50g [women] of alcohol per typical using day);
and (3) heavy drinkers (consumed more than 70g [men] or 50g [women] per typical
using day). The analysis showed that at the start of the study, 49% of men and 43% of
women were defined as heavy drinkers. At the 3-year follow-up, the proportion of
heavy drinkers had dropped for both groups – to 26% of men and 28% of women.
The results showed that abstainers were the lowest offenders in terms of certain
crimes, including assault. Logistic regression was used to investigate the link between
drinking and drug usage at the 3-year follow-up. It was found that abstainers used
heroin and other drugs less frequently. The authors state that their results show that
the link between drug and alcohol use is complex, and that other factors, such as
gender, age and ongoing or changing alcohol and drug use, need to be considered
when assessing and planning treatment for opiate users in order to target their
treatment effectively.
Concurrent cocaine use among opiate users (Cox and Comiskey 2011)
Current cocaine use was defined as use of any cocaine powder or crack in the 90 days
before the follow-up interview. At recruitment, 48% of participants reported using
cocaine. There were no significant differences in the demographic characteristics of
72
those who used cocaine and those who did not. However, cocaine users were
significantly more likely to report use of heroin, non-prescribed methadone, nonprescribed benzodiazepines, cannabis and alcohol. They were also more likely to
reported injecting. At 1-year follow-up, overall, cocaine users showed reductions in
drug use, injecting behaviours, acquisitive crime and a reduction in physical and mental
health symptoms. However, analysis of the differences between the original cocaine
users and non-users showed that cocaine users were more likely to have used heroin,
cocaine and crack in the 90 days prior to their follow-up interview. They were more
likely to have committed an acquisitive crime and to have sold or supplied drugs.
Logistic regression analysis was conducted to determine the use of cocaine as a
predictor variable for unsuccessful treatment outcomes. This showed that those who
used cocaine at intake were more likely to have used cocaine at follow-up, to have
been homeless within the previous three months and to have committed any crime.
The authors conclude that there is no evidence to show cocaine use among this group
affected treatment outcomes at one year.
Over-the-counter (OTC) opiate misuse
Information on the misuse of OTC opiates is limited in Ireland and internationally.
Researchers at St Patrick’s University Hospital, Dublin, have examined the clinical
profiles, treatment and prevalence of patients admitted in a 12-month period with a
diagnosis of OTC opiate abuse (Thekiso and Farren 2010).
All inpatient records between 1 April 2007 and 30 April 2008 were retrospectively
reviewed, and 20 patients were identified as having a diagnosis of either harmful use of
an OTC opiate or dependency. These patients represented 0.6% of all patients
admitted during that period, and 4% of all patients diagnosed with mental or
behavioural disorder owing to psychoactive substances. Of the 20 patients, 70% had a
diagnosis of opiate dependency and 30% of harmful opiate use. In addition, all but one
(95%) had a diagnosis of co-morbid psychiatric illness. Codeine was the opiate
misused in all 20 cases, and all cases reported using a combination-type OTC opiate,
that is, codeine with paracetamol (e.g. Solpadine) or codeine with ibuprofen (e.g.
Nurofen Plus). Fifteen patients received treatment for opiate withdrawal.
Some of the other main findings of the study were:
 the mean age of the 20 patients studied was 49 years;
 13 were female;
 13 had a history of harmful use of or dependency on alcohol;
 eight had a history of harmful use of or dependency on benzodiazepines;
 16 reported daily use;
 four reported chronic pain;
 seven relapsed within six months;
 15 obtained the drug over the counter; and
 five obtained the drug over the internet.
Although the numbers in the study were small, the high rates of polysubstance misuse
and co-morbid psychiatric illness among the cases reviewed are consistent with the
findings of similar research internationally. The authors note with concern that the
average reported amount of codeine taken daily was high (261mg), and suggest that
this is likely to have been an under-estimation. They point out that, to ingest such a
large amount of codeine in the form of an OTC product, an individual would have to
take correspondingly large daily doses of the combination compounds, usually
paracetamol or ibuprofen, which greatly increases the risk of side-effects or overdose
from both products. The authors suggest preventative measures, such as reducing the
number of tablets per pack and placing an additional health warning on packaging.
They state that any move to make OTC opiates prescription-only needs to be carefully
considered, taking account of the increase in pressure on GPs and the reduction in
patient autonomy that such a move might cause.
73
See ‘Pharmacy guidelines on safe supply of codeine-based products’ in Chapter 7.2 for
an account of newly introduced pharmacy guidelines, which provide for the safe
dispensing of OTC opiate products in Ireland; these products can now be dispensed
only under the supervision of a pharmacist.
Alcohol-dependent clients with a dual diagnosis
A recent prospective Irish study aimed to determine the predictors of treatment
outcome of a group of alcohol-dependent participants, who had a dual diagnosis of
either bipolar or unipolar effective disorder, after in-patient treatment (Farren and
McElroy 2010). The treatment programme started in 2003. Of the 183 participants,
29% had a history of illegal drug abuse and 24% had a history of prescription drug
abuse. At six months, 162 of the participants could be included in the follow-up.
There were no significant differences in demographic characteristics, diagnoses or
number of previous admissions between those who relapsed to alcohol use between
three and six months after treatment.
Logistic regression modelling was used to identify predictors of relapse (to alcohol
use). This showed that a history of illegal drug abuse at admission was a significant
predictor of relapse at six months after treatment. Other significant predictors were
baseline anxiety levels, level of depression at admission and high baseline AUDIT
(Alcohol Use Disorders Identification Test) score.
Another interesting finding was that those who organised to attend aftercare before
they were discharged were less likely to relapse. Rehospitalisation within three months
of treatment was also found to be a significant protective factor and to lead to a
reduction in drinking among early relapsers. The study had limitations. It was
conducted in a private hospital where most clients have private health insurance. Also,
pharmacotherapy adherence was not measured. The authors recommend that dual
diagnosis treatment programmes should address both alcohol and drug use in order to
reduce the risk of relapse.
Treated problem benzodiazepine use
An analysis of treated problem benzodiazepine use as recorded by the NDTRS
between 2003 and 2008, and poisoning deaths where a benzodiazepine was
implicated as recorded by the NDRDI between 1998 and 2007, was published in
December 2010 (Bellerose, et al. 2010). This is the first time that data from the NDTRS
and the NDRDI have been presented together, providing a more complete picture of
problem benzodiazepine use and its consequences. The main findings are summarised
below.
In the period 2003–2008 the annual number of treated cases reporting a
benzodiazepine as a problem substance increased by just over 63%, rising from 1,054
in 2003 to 1,719 in 2008 (Table 5.5.1). The number of cases who reported a
benzodiazepine as their main problem substance was relatively small, but increased by
120%, from 76 in 2003 to 167 in 2008. The number of cases who reported a
benzodiazepine as an additional problem substance was much larger, and increased
by 59%, from 982 in 2003 to 1,562 in 2008. These increases may be explained by a
combination of factors: an increase in the number of treatment places, an increase in
problem benzodiazepine use among the population and an increase in reporting to the
NDTRS.
Table 5.5.1 Benzodiazepine cases entering treatment by treatment status, NDTRS 2003–2008
All cases*
Benzodiazepine as a main
problem
Benzodiazepine as an
additional problem
2003
2004
2005
2006
2007
2008
n (%)
1054
n (%)
1026
n (%)
1115
n (%)
1222
n (%)
1225
n (%)
1719
76 (7.2)
103 (10.0)
75 (6.7)
96 (7.9)
163 (13.3)
167 (9.7)
982 (93.2)
928 (90.4)
1044
(93.6)
1129
(92.4)
1064
(86.9)
1562
(90.9)
74
2003
2004
2005
2006
2007
2008
816
758
810
839
787
1113
87 (7.8)
Previously treated cases*
Benzodiazepine as a main
problem
Benzodiazepine as an
additional problem
New cases*
Benzodiazepine as a main
problem
49 (6.0)
50 (6.6)
30 (3.7)
40 (4.8)
72 (9.1)
770 (94.4)
711 (93.8)
782 (96.5)
802 (95.6)
715 (90.9)
214
231
275
352
415
1032
(92.7)
576
27 (12.6)
47 (20.3)
42 (15.3)
50 (14.2)
85 (20.5)
74 (12.8)
Benzodiazepine as an
additional problem
188 (87.9)
186 (80.5)
235 (85.5)
302 (85.8)
332 (80.0)
505 (87.7)
24
37
30
31
23
30
Treatment status unknown
* The sum of ‘main problem’ and ‘additional problem’ cases may exceed the total number of cases in these treatment status categories
as some cases reported one type of benzodiazepine as their main problem substance and another type of benzodiazepine as an
additional problem substance.
Source: (Bellerose, et al. 2010)
Between 1998 and 2007 benzodiazepines were implicated in 649 deaths by poisoning,
which accounted for 31% of all such deaths recorded by the NDRDI for the 10-year
period. The annual number of deaths in which benzodiazepines were implicated was
consistently high, and increased from 65 in 1998 to 88 in 2007 (Table 5.5.2).
Table 5.5.2 Proportion of poisonings where benzodiazepines were implicated, NDRDI 1998– 2007
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
n (%) n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
Total poisonings
178
187
182
178
211
185
207
248
270
274
(n = 2,120)
Benzodiazepines
65
56
61
47
61
54
63
66
88
88
(n = 649)
(36.5) (29.9) (33.5) (26.4) (28.9) (29.2) (30.4) (26.6) (32.6) (32.1)
Source: (Bellerose, et al. 2010)
The majority (78%) of cases treated for a benzodiazepine as their main problem
substance used more than one problem substance. Alcohol was the most common
additional problem substance, reported by 52% of cases, followed by cannabis (43%)
and opiates (40%). The main problem substances reported where a benzodiazepine
was the additional problem substance were opiates (80%), alcohol (9%), cannabis
(5%) and cocaine (5%). It is generally accepted that the use of several substances
increases the complexity of these cases and is associated with poorer treatment
outcomes. Problem use of benzodiazepines needs to be approached in the context of
multiple substance use. The types of intervention and treatment setting very much
depend on the individual’s current problem substance use and history of substance use
and on the treatment services available.
The additional substances most frequently involved in poisoning deaths where a
benzodiazepine was implicated were alcohol (41%) and methadone (36%). Alone,
these substances may not be sufficient to cause death, but it is likely that the
respiratory depressant effect is amplified when these substances are taken together,
increasing the risk of fatal overdose.
The median age of new cases entering treatment for a benzodiazepine as their main
problem substance decreased from 34 to 25 years over the reporting period, while the
median age of previously treated cases remained stable, ranging between 27 and 29
years. The median age of cases entering treatment and reporting a benzodiazepine as
an additional problem substance increased from 24 to 26 years for new cases, and
from 27 to 30 years for previously treated cases. Although the numbers were small, the
proportion of cases aged under 18 years increased steadily between 2003 and 2008,
and was highest among new cases who presented with a benzodiazepine as their main
problem substance. This finding has implications for health promotion, drug awareness
campaigns and service provision for this vulnerable age group.
The median age of those who died as a result of poisoning where a benzodiazepine
was implicated ranged between 33 and 39 years over the reporting period. Just over
75
half (51%) were not alone at the time of their death. The majority of poisonings
occurred in a private dwelling.
Approximately 70% of all benzodiazepine cases treated in the period 2003–2008 were
males and the proportion was the same for new cases and for previously treated
cases. However, the male to female ratio differed depending on whether
benzodiazepines were reported as a main or an additional problem substance. Over
the six-year period, females accounted for 40% of cases where benzodiazepine was
the main problem and for 30% of cases where benzodiazepine was an additional
problem substance. Among those who reported a benzodiazepine as their main
problem substance and who had no history of opiate use, there were higher
proportions of female cases in the older age groups and higher proportions of male
cases in the younger age groups. Similarly, among those who died, there were higher
proportions of females in the older age groups and higher proportions of males in the
younger age groups.
Age, gender, history of opiate use and whether benzodiazepines are a main or an
additional problem substance are all factors that need to be considered by services
treating this population. The increasing number of cases in treatment and the number
of deaths among the population support the findings of the 2006/7national drug
prevalence survey, which show that 11% of all adults have used sedatives or
tranquillisers (which include benzodiazepines) at some point in their lives (National
Advisory Committee on Drugs and Drug and Public Health Information and Research
Branch 2009). Prescribers and users need to be made more aware of the potentially
fatal effects of benzodiazepines used in conjunction with other substances. Identifying
and controlling possible illicit sources of benzodiazepines is also necessary, but it is
equally important to revisit the clinical guidelines on benzodiazepine prescribing
(Department of Health and Children 2002).
Treated problem drug use reported by the NDTRS (2004–2009)
Table 5.5.3 shows an overview of main problem drug for all cases entering treatment,
as reported to the NDTRS between 2004 and 2009. In 2009, opiates were the most
common problem drug (59%), followed by cannabis (23%) and cocaine (11%). The
proportion and number of opiate users remained stable between 2004 and 2008 but
decreased slightly in 2009. The number of cases reporting cannabis as their main
problem substance increased between 2004 and 2006, dropped in 2007 and increased
again to its highest level in 2009, with 1,519 cases. Following a steady increase until a
peak in 2007, the number of cases reporting cocaine as their main problem substance
decreased slightly in 2008 and 2009.
Overall, while the number of opiate cases increased, the proportion of opiate users
among previously treated cases decreased over the reporting period from 83% in 2004
to 75% in 2009. There is a growing proportion of cases returning to treatment for
problem drug use other than opiates, such as cannabis or benzodiazepines.
Table 5.5.3 Main problem drug used by cases entering treatment (NDTRS 2004–2009)
2004
2005
2006
2007
2008
n (%)
n (%)
n (%)
n (%)
n (%)
All cases
4506
4877
5238
5749
6322
2863
3094
3326
3627
4004
Opiates
(63.5)
(63.4)
(63.5)
(63.1)
(63.3)
Ecstasy
139 (3.1)
124 (2.5)
95 (1.8)
129 (2.2)
103 (1.6)
Cocaine
331 (7.3)
467 (9.6)
552 (10.5) 777 (13.5) 762 (12.1)
Amphetamines
23 (0.5)
36 (0.7)
30 (0.6)
39 (0.7)
36 (0.6)
Benzodiazepines
103 (2.3)
75 (1.5)
96 (1.8)
163 (2.8)
167 (2.6)
Volatile inhalants
31 (0.7)
27 (0.6)
23 (0.4)
32 (0.6)
28 (0.4)
1039
1097
1192
Cannabis
991 (22.0)
963 (16.8)
(21.3)
(20.9)
(18.9)
Others
25 (0.6)
15 (0.3)
19 (0.4)
19 (0.3)
30 (0.5)
Cannabis
224 (8.8)
219 (7.9)
260 (9.2)
259 (8.2)
330 (9.4)
2009
n (%)
6497
3862
(59.4)
64 (1.0)
696 (10.7)
33 (0.5)
260 (4.0)
21 (0.3)
1519
(23.4)
42 (0.6)
443 (12.9)
76
2004
n (%)
12 (0.5)
Others
2005
n (%)
6 (0.2)
2006
n (%)
9 (0.3)
2007
n (%)
7 (0.2)
2008
n (%)
12 (0.3)
2009
n (%)
16 (0.5)
Source: Unpublished data NDTRS
5.6
Trends in treated population and treatment provision (incl.
numbers)
A summary of the Treatment Demand Indicator (TDI) data (also see TDI data), as
provided by the NDTRS, shows that 8,511 cases entered treatment in 2010, an
increase of 1,240 cases since 2009.10 The increase between 2009 and 2010 may be
due to an increase in services returning data to the NDTRS, or may reflect a genuine
increase in the number of cases entering treatment in 2010. In 2010, 43% (3,740) were
new entrants to treatment, a decrease on the proportion reported in 2009 (47.2%). As
in previous years, in 2010 the majority of cases attended outpatient services (63.0%,
5,359).
Again, as in previous years, opiates (mainly heroin) were the most common main
problem drug reported by cases entering treatment in 2010 (57.9%, 4,930). The
number and proportion of cases treated for cocaine dropped from 11.7% (837) in 2009
to 10.0% (850) in 2010. The number of deaths where cocaine was implicated dropped
in 2009 which supports this downward trend (see Chapter 6.4.1).
The biggest change between 2009 and 2010 was the difference in the number of ‘other
substances reported’, owing to the appearance of cases seeking treatment for head
shop drugs. In 2009, less than 20 cases reported a headshop drug as their main
problem substance, but in 2010, 217 cases reported headshop drugs as their main
problem substance. This increase could have been due to one or more of several
factors including improved reporting to the NDTRS, an increase in services providing
treatment for these substances, or an increase in the number of cases seeking
treatment for these substances. In 2010, legislation was brought in which made a
number of these substances illegal in Ireland (see Chapter 1.2.2 for details of this
legislation). However, in 2010, cases seeking treatment for headshop drugs only
represented 2.5% of the total number of cases.
The demographic profile of those treated in 2010 was similar to previous years. Three
quarters (75.5%, 6,429) of those in treatment were male, the mean age was 28 years,
and the majority were unemployed (62.8%, 5,345).
10
It should be noted that the selection of NDTRS data for national analysis differs slightly to the selection of data for
TDI; therefore, there are some differences between what is reported in TDI and what is published in HRB Trend papers
and web updates.
77
6.
Health Correlates and Consequences
6.1
Introduction
Problematic drug use can be associated with a number of other health conditions or
lead to a range of health consequences, including drug-related infectious diseases,
drug-related overdoses, a range of chronic illnesses and acute conditions, and
psychiatric comorbidity. Information on these various health correlates and
consequences is collected in a variety of information systems, which are described
below.
The Health Protection Surveillance Centre (HPSC) is Ireland’s specialist agency for
the surveillance of communicable diseases. Part of the Health Service Executive
(HSE), and originally known as the National Disease Surveillance Centre, the HPSC
endeavours to protect and improve the health of the Irish population by collating,
interpreting and disseminating data to provide the best possible information on
infectious disease. The HPSC has recorded new cases among injecting drug users of
HIV since 1982, hepatitis B since 2004, and hepatitis C since 2006.
The HIPE (Hospital In-Patient Enquiry) is a computer-based health information
system, managed by the Economic and Social Research Institute (ESRI) in association
with the Department of Health and the HSE. It collects demographic, medical and
administrative data on all admissions, discharges and deaths from acute general
hospitals in Ireland. It was started on a pilot basis in 1969 and then expanded and
developed as a national database of coded discharge summaries from the 1970s
onwards. Each HIPE discharge record represents one episode of care; each discharge
of a patient, whether from the same or a different hospital, or with the same or a
different diagnosis, gives rise to a separate HIPE record. The scheme, therefore,
facilitates analyses of hospital activity rather than of the incidence of disease. HIPE
does not record information on individuals who attend accident and emergency units
but are not admitted as inpatients.
The National Poisons Information Centre (NPIC), located in Beaumont Hospital,
Dublin, provides a national telephone information service on the toxicity, features and
management of cases of poisoning. This 24-hour service is offered mainly to doctors
and other health care professionals. Queries are dealt with by poisons information
officers at the Centre between 8 am and 10 pm daily, while out-of-hours calls are
automatically diverted to the UK National Poisons Information Service (NPIS). Data
from this source provide indications of the pattern of human cases of poisoning,
including age, gender and agent.
The data collected by the Primary Care Re-imbursement Service (PCRS), previously
called the General Medical Services (GMS) Payments Board, are another source of
information on the health correlates and consequences of problematic drug use among
those who have medical cards, which are means-tested. Medical-card holders
received certain health services, including approved prescribed drugs and medicines,
free of charge up to December 2009 and since January 2010 for a minimal charge.
Operated by the HSE, the PCRS administers payments to doctors, pharmacists and
dentists who provide services under the PCRS scheme.
The National Psychiatric In-Patient Reporting System (NPIRS), administered by the
Health Research Board (HRB), is a national psychiatric database that provides detailed
information on all admissions to and discharges from 56 inpatient psychiatric services
in Ireland. It records data on cases receiving inpatient treatment for problem drug and
alcohol use. NPIRS does not collect data on the prevalence of psychiatric comorbidity
in Ireland. The HRB publishes an annual report on the data collected in NPIRS, entitled
Activities of Irish psychiatric units and hospitals.
Problematic drug use can also lead to premature death. Death can occur as a result of
overdose (either intentional or unintentional), actions taken under the influence of
78
drugs, medical consequences or incidental causes. Although illicit drugs are involved in
many cases of drug-related death, licit (including prescribed) drugs are also frequently
involved, either alone or in conjunction with an illicit drug. Alcohol has been reported as
the third greatest risk factor for ill health and premature death in Europe. Established in
2005, the National Drug-Related Death Index (NDRDI), which is maintained by the
HRB, is an epidemiological database which records cases of death by drugs poisoning,
and deaths among drug users in Ireland, extending back to 1998. The NDRDI also
records data on alcohol-related poisoning deaths, deaths among those who are alcohol
dependent, extending back to 2004.
The Central Statistics Office (CSO), acting on behalf of the Department of Health,
compiles quarterly and annual statistical reports on deaths in the Irish population.
These reports are based on administrative data supplied by the General Register
Office. The principal variables collected include date of death, address of residence of
deceased, place of death, underlying cause of death, occupation, age, sex, and marital
status. Since 1 January 2007 the underlying cause of death has been coded according
to ICD10 rather than ICD9.
The National Registry of Deliberate Self-Harm is a national system of population
monitoring for the occurrence of deliberate self-harm, established at the request of the
Department of Health and Children, by the National Suicide Research Foundation
(National Parasuicide Registry Ireland 2004). Since 2006/07 the Registry has achieved
complete national coverage of hospital-treated deliberate self-harm. The Registry
defines deliberate self-harm as ‘an act with non-fatal outcome in which an individual
deliberately initiates a non-habitual behaviour, that without intervention from others will
cause self-harm, or deliberately ingests a substance in excess of the prescribed or
generally recognised therapeutic dosage, and which is aimed at realising changes that
the person desires via the actual or expected physical consequences’. All methods of
deliberate self-harm are recorded in the Registry, including drug overdoses and alcohol
overdoses, where it is clear that the self-harm was intentionally inflicted. All individuals
who are alive on admission to hospital following a deliberate act of self-harm are
included. Not considered deliberate self-harm are accidental overdoses, e.g. an
individual who takes additional medication in the case of illness, without any intention
to self-harm; alcohol overdoses alone, where the intention was not to self-harm;
accidental overdoses of street drugs (drugs used for recreational purposes), without
the intention to self-harm; and individuals who are dead on arrival at hospital as a result
of suicide.
6.2
Drug-related infectious diseases
6.2.1
HIV/AIDS and viral hepatitis
Update on blood-borne viral infections in injecting drug users
HIV surveillance in 2010
Voluntary linked testing for antibodies to HIV has been available in Ireland since 1985.
According to the most recent report of the HPSC, at the end of 2010 there were 5,700
diagnosed HIV cases in Ireland, of which 1,469 (26%) were probably infected through
injecting drug use (O'Donnell, Kate, et al. 2011). Figure 6.2.1 presents the number of
new cases of HIV among injecting drug users reported in Ireland, by year of diagnosis;
data from 1982 to 1985 are excluded as these four years were combined in the source
records. There was a fall in the number of HIV cases among injecting drug users
between 1994 and 1998, with about 20 cases per year, compared to about 50 cases
each year in the preceding years. There was a sharp increase in the number of cases
in 1999 (69 new cases), which continued into 2000 (83 new cases). Between 2001 and
2010 there was an overall decline in the number of new injector cases when compared
to 2000. It was difficult to interpret the trend owing to the relatively small numbers
diagnosed each year, so a smoother curve (grey plot line in Figure 6.2.1.1) was
79
calculated using a rolling centred three-year average. This curve presents a declining
trend since 2006 and a return to low number of cases in the mid-nineties.
Of the 22 new HIV cases reported in 2010, 18 were male and four were female, and
the median age among intravenous drug users (IDUs) was 32.5 years (range 19–50
years), with 12 aged 34 years or younger. Eight cases (36.4%) were born in Ireland
and another eight (36.4%) in central and eastern Europe. Nine new cases were Irish,
eight cases were not Irish and five cases had no country of origin recorded. At the time
of HIV diagnosis, 11 of the new cases among IDUs were asymptomatic, two had AIDS
and two had an acute HIV infection.
120
100
Number
80
60
40
20
0
Actual number
Rolling centred three year
average number
19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20
86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10
112 72 58 57 50 34 82 52 20 19 20 21 26 69 83 38 50 49 71 66 57 54 36 30 22
81 62 55 47 55 56 51 30 20 20 22 39 59 63 57 46 57 62 65 59 49 40 29
Figure 6.2.1.1 Actual number and rolling average number of new cases of HIV among injecting
drug users, by year of diagnosis, reported in Ireland, 1986–2010
Source: Unpublished data reported to Department of Health and Children, National Disease Surveillance Centre and HPSC.
Blood-borne viral status among a population attending a Dublin maternity
hospital by exposure to methadone
Cleary and colleagues (Cleary, et al. 2011) examined the relationship between
methadone maintenance treatment and maternal characteristics, including blood-borne
viral status. This was a retrospective cohort study of 61,030 singleton births at a large
maternity hospital from 2000 to 2007, based on antenatal, delivery and postnatal
records and the Central Treatment List (of clients prescribed methadone). Of the
61,030 singleton births, 618 (1%) were to women who were prescribed methadone at
delivery. A higher proportion of methadone-exposed women were likely to test positive
for hepatitis B, hepatitis C and HIV when compared to non-exposed women (Table
6.2.1.1).
Table 6.2.1.1 Blood-borne viral status in 61,030 singleton births at a large Dublin maternity
hospital, 2000–2007, by exposure to methadone
Exposed to methadone*
Non-exposed*
n (%)
n(%)
Hepatitis B positive serological status
20 (3.5)
326 (1.0)
Hepatitis C positive serological status
275 (48.2)
193 (0.6)
HIV positive
35 (5.8)
171 (0.3)
*The total number tested in each group is not presented in the paper.
Source: (Cleary, et al. 2011)
6.2.2
STI’s and tuberculosis
The surveillance data available in Ireland does not identify drug use as a risk factor for
these infections.
6.2.3
Other infectious morbidity (e.g. abscesses, sepses, endocarditis, wound
botulism)
80
Soft tissue abscess development among IDUs
Maloney and colleagues (Maloney, et al. 2010) identified the risk factors for soft tissue
abscesses among IDUs in order to enhance initial assessment of drug users’ needs.
The study was done using a convenience sample drawn from those attending a
methadone treatment centre in Dublin. Eighty IDUs were asked to take part in the study
and 70 (88%) agreed. The respondents completed a 10–15 minute structured interview
in January 2007. Three-fifths of the sample were men and the average age was 30.4
years. The youngest interviewee was 21 years old and the oldest 53 years old. All were
prescribed methadone for the treatment of opiate dependence. Thirty-four (49%)
reported being on methadone treatment for more than five years, 28 (40%) on
methadone treatment for between one and five years and eight (11%) for between one
week and a year. Twenty-six (37%) had commenced injecting illicit drugs on or before
their eighteenth birthday, 21 (30%) had commenced between the ages of 19 and 23
years, 17 (24%) between the ages of 24 and 28 years, and only six (9%) on or after
their 29th birthday.
Forty-eight (69%) participants had had an abscess at some stage and 23 (33%) had
had an abscess in the year prior to the study. Eleven (16%) of the 70 had had an
abscess once since commencing injecting, 19 (27%) between two and four times, 14
(20%) between 5 and 10 times, and four (6%) more than ten times. All the respondents
injected heroin, 57 injected cocaine and seven injected flurazepam. The respondents
were asked about the frequency of heroin or cocaine use prior to the development of
their last abscess (see Table 6.2.3.1). A high proportion of those who developed an
abscess had injected heroin all or most of the time, while injecting cocaine and the
development of an abscess were not linked to frequency of injecting cocaine.
Table 6.2.3.1 Number (%) of attenders at a methadone treatment centre in Dublin with abscess, by
frequency of injecting cocaine or heroin (n=48)
Heroin
Cocaine
Frequency injecting
n (%)
n (%)
Always
13 (27)
2 (4)
Most of the time
27 (56)
17 (35)
Occasionally
5 (10)
9 (19)
Rarely
3 (6)
14 (29)
Source: (Maloney, et al. 2010)
When they first injected, 63 (90%) injected into one of the veins in their left or right
antecubital fossa (a small cavity in the elbow joint), and 38 (54%) had an abscess in
one of the two fossae at some point in their life. Twenty-four participants reported that
they injected into a vein in the groin for the last or most recent injection administered.
Thirty respondents said that they had ever injected into the veins in their groin and of
these, 14 (47%) had an abscess. Forty-six (66%) respondents reported that they
injected under the skin (skin-popping) rather than into the vein and, of these, 33 (72%)
had between two and ten abscesses.
Twenty per cent (14) of participants did not clean their skin before injecting, while 13%
(nine) always cleaned their skin with an alcohol wipe. Most injectors injected in a public
place which reduced their opportunity for hygienic practices. Eighty per cent shared
one or more types of injecting equipment (see Table 6.2.3.2). Fifty-one per cent shared
needles, 59% shared syringes, 80% shared spoons or pots for preparing the drug, 56%
shared filters and 61% shared water. Given the hygienic and sharing practices, it is not
surprising 69% of participants had at least one abscess and 80% reported that they
were hepatitis C positive. The authors conclude that healthcare professionals need to
develop better strategies for delivering messages to clients about safer injecting
behaviour.
Table 6.2.3.2 Number (%) of injecting drug users attending a methadone treatment centre in Dublin,
by sharing injecting equipment and frequency of such sharing (n=70)
Frequency of
Needle Syringe Spoon/pot
Filter
Water
Drug
sharing
n (%)
Always
1 (1)
0 (0)
1 (1)
0 (0)
1 (1)
0 (0)
81
Frequency of
sharing
Most of the time
Occasionally
Rarely
Needle
Syringe
Spoon/pot
Filter
Water
Drug
9 (13)
14 (20)
12 (17)
11 (16)
16 (23)
14 (20)
22 (31)
27 (39)
6 (9)
12 (17)
19 (27)
15 (21)
22 (31)
5 (7)
24 (34)
25 (36)
2 (3)
Never
34 (49)
29 (41)
14 (20)
27 (39)
19 (27)
8 (11)
31 (44)
Source: (Maloney, et al. 2010)
MRSA and MSSA among attenders at a Dublin methadone clinic
Ninety-six of 183 clients attending methadone treatment at the Drug Treatment Centre
Board in Dublin were randomly selected to complete a 12-item questionnaire, to
provide nasal swabs to be tested for meticillin resistant Staphylococcus aureus (MRSA)
and meticillin sensitive Staphylococcus aureus (MSSA) and to provide blood samples
for viral analysis (Somers, et al. 2010).
Of the 96 nasal swab specimens submitted for culture and identification, 3.1% grew
MRSA and 25% grew MSSA. The serological analysis revealed that 73% of the clients
were hepatitis C positive and 12% were HIV positive.
Seventy-three per cent of the sample were men, 27% had been in prison in the year
prior to the survey and 86% had been in prison at least once in their life. One quarter
had been homeless at some stage in the preceding 12 months and 27% lived alone.
Seventeen per cent had snorted cocaine in the year prior to the survey and 24% had
injected it. Forty- eight per cent had injected heroin in the 12 months prior to the
survey, and 53% had injected either heroin or cocaine. All injectors had attended
needle-exchange services at least once in the 12 months prior to data collection; only
7% had shared needles, while 18% had shared other injecting equipment. Twenty-eight
per cent reported at least one soft-tissue abscess in the past year, 71% had had one or
more courses of antibiotics, and 40% had had at least one hospital admission.
As the prevalence of MRSA was low and the sample size very small, it was not
possible to identify factors associated with MRSA carriage among those in methadone
treatment. The prevalence of MRSA in the opiate-dependent population in Dublin is
lower than that in Brighton (49%) and Vancouver (19%) but higher than in Italy (1.1%).
6.2.4
Behavioural data
There are no routine collections of behavioural data in Ireland. See study presented in
Section 6.2.3 and Table 6.2.3.2.
6.3
Other drug-related health correlates and consequences
6.3.1
Non-fatal overdoses and drug related emergencies
National Registry of Deliberate Self-Harm annual report 2010
The ninth annual report from the National Registry of Deliberate Self-Harm was
published in July 2011 (O'Donnell, Kate, et al. 2011). The report contains information
relating to every recorded presentation of deliberate self-harm to hospital emergency
departments in 2010, giving complete national coverage of hospital-treated deliberate
self-harm.
In 2010, there were 11,966 recorded presentations of deliberate self-harm, involving
9,630 individuals. The rate of presentations increased from 209/100,000 of the
population in 2009 to 217/100,000 in 2010, a 4% increase. Of the 9,630 individuals
who presented after an episode of deliberate self-harm, 86% were presenting for the
first time in their life.
Concordant with previous reports, 47% of self-harm presentations in 2010 were men
and the same proportion were aged under 30 years. Two hundred and seventy-five
82
(2.3%) were living in hostels for the homeless or had no fixed abode. Presentations
peaked in the hours around 10pm and were highest on Sundays and Mondays; 32% of
deliberate self-harm episodes occurred on these two days. There was evidence of
alcohol consumption in 41% of all presentations and this was more common among
men (44%) than women (37%).
Drug overdose was the most common form of deliberate self-harm (71%, n=8,538),
with overdose rates being higher among women (77%) than among men (65%). The
total number of tablets taken was known in 73% of cases: on average, 31 tablets were
taken these cases of drug overdose. Forty-two per cent of all drug overdoses involved
a minor tranquilliser, 29% involved medicines containing paracetamol and 21%
involved anti-depressants/mood stabilisers. The number of deliberate self-harm
presentations involving street drugs increased in 2009 (579) and 2010 (645) when
compared to 2008 (461). Men are much more likely to self-harm using street drugs
than women.
The next step or referral outcome was recorded for 90% of deliberate overdose cases
and were as follows: discharged home (41%), admission to an acute general hospital
(37%), admission to psychiatric in-patient care (7%), refused admission to any hospital
(0.6%), and self-discharge before advice (14%).
The report recommends the following measures to reduce the incidence of deliberate
self-harm:
 a wide range of evidence-based treatments and aftercare programmes,
 uniform assessment and aftercare procedures,
 adequate services to deal with alcohol and depression at peak times,
 information for the general public on the common symptoms of depression,
signs of suicidal behaviour and places where help is available, and
 a national strategy to deal with alcohol supply and illegal alcohol use among
children aged under 18 years.
Non-fatal overdoses and drug-related emergencies
Data extracted from the Hospital In-Patient Enquiry (HIPE) scheme were analysed to
determine trends in non-fatal overdoses discharged from Irish hospitals in 2009. There
were 4,202 overdose cases in that year, of which 30 died in hospital. The 4,172
discharged cases are included in this analysis. The number of overdose cases
decreased by 13% between 2008 and 2009 (Figure 6.3.1.1).
6000
5000
Number
4000
3000
2000
1000
0
Overdoses
2005
5012
2006
4840
2007
4918
2008
4772
2009
4172
Figure 6.3.1.1 Overdose cases by year, 2005–2009 (N=23,714)
Source: Unpublished HIPE data
83
In the years 2005–2009 there were more overdose cases among females than among
males (Figure 6.3.1.2), with females accounting for 54% of all overdose cases in 2009.
3000
2500
Number
2000
1500
1000
500
0
Female
Male
2005
2794
2218
2006
2605
2235
2007
2691
2227
2008
2640
2132
2009
2258
1914
Figure 6.3.1.2 Overdose cases by gender, 2005–2009 (N=23,714)
Source: Unpublished HIPE data
In the four-year period 2005–2008, one quarter of overdoses occurred in those aged
15–24 years, with the incidence of overdose decreasing with age (Figure 6.3.1.3). The
number of under-25s fell in 2009, accounting for 32% (n=1,328) of overdose cases,
compared to 40% (n=2,015) in 2005.
1400
1200
Number
1000
800
600
400
200
0
2005
2006
2007
2008
2009
0-14
740
701
550
560
353
15-24
1275
1269
1287
1233
975
25-34
1017
942
995
1026
887
35-44
882
835
893
867
845
45-54
581
575
624
543
576
55-64
282
273
312
274
281
65-74
140
126
136
148
140
75-84
70
98
99
90
85
85+
25
21
22
31
30
Figure 6.3.1.3 Overdose cases by age group, 2005–2009 (N=24,314)
Source: Unpublished HIPE data
Table 6.3.1.1 presents the positive findings per category of drugs and other substances
involved in all cases of overdose in 2009. Non-opioid analgesics were present in 36%
(1,518) of cases. Paracetamol is included in this drug category and was present in 27%
(1,129) of cases. Psychotropic agents were taken in 22% (903) and benzodiazepines in
25% (1,053) of cases. There was evidence of alcohol consumption in 13% (534) of
cases. Cases involving alcohol are included in this analysis only when the alcohol was
used in conjunction with another substance.
Table 6.3.1.1 Category of drugs involved in overdose cases, 2009 (N=4,172)
Positive findings per
Drug category
drug category*
Non-opioid analgesics
n
1518
%
36.4
Benzodiazepines
1053
25.2
Psychotropic agents
903
21.6
Anti-epileptic / Sedative / Anti-Parkinson agents
556
13.3
84
Positive findings per
drug category*
539
12.9
Drug category
Narcotics and hallucinogens
Alcohol
534
12.8
Systemic and haematological agents
201
4.8
Cardiovascular agents
158
3.8
Autonomic nervous system agents
128
3.1
Anaesthetics
116
2.8
Hormones
100
2.4
Systemic antibiotics
94
2.3
Gastrointestinal agents
74
1.8
Other chemicals and noxious substance
58
1.4
Diuretics
51
1.2
Muscle and respiratory agents
45
1.1
Topical agents
25
0.6
Anti-infectives / Anti-parasitics
23
0.6
Other gases and vapours
Other and unspecified drugs
7
0.2
981
23.5
*The sum of positive findings is greater than the total number of cases because some cases involved more than one drug or substance.
Source: Unpublished data from HIPE
Narcotic or hallucinogenic drugs were involved in 13% (539) of overdose cases in
2009. Figure 6.3.1.4 shows the number of positive findings of drugs in this category
among the 539 cases. The sum of positive findings is greater than the total number of
cases because some cases involved more than one drug from this category. Opiates
were used in 82% of the cases, cocaine in 17% and cannabis in 9%.
500
443
450
400
Number
350
300
250
200
150
92
100
46
50
11
0
Opiates
Cocaine
Cannabis
Other hallucinogens
Figure 6.3.1.4 Narcotics and hallucinogens involved in overdose cases, 2009 (N=539)
Source: Unpublished data from HIPE
In 70.3% of cases the overdose was classified as intentional (Figure 6.3.1.5).
3500
3000
Number
2500
2000
1500
1000
500
0
2009
Accidental
702
Intentional
2879
Undetermined
515
85
Figure 6.3.1.5 Overdose cases by classification, 2009 (N= 4,096)
Source: Unpublished data from HIPE
Table 6.3.1.2 presents the positive findings per category of drugs and other substances
involved in cases of intentional overdose in 2009. Non-opioid analgesics were involved
in 43% (1,236) of cases, benzodiazepines in 28% (816) and psychotropic agents in
25% (728).
Table 6.3.1.2 Category of drugs involved in intentional overdose cases, 2009 (N=2,879)
Positive findings per
Drug category
drug category*
Non-opioid analgesics
n
1236
%
42.9
Benzodiazepines
816
28.3
Psychotropic agents
728
25.3
Anti-epileptic / Sedative / Anti-Parkinson agents
451
15.7
Alcohol
402
14.0
Narcotics and hallucinogens
293
10.2
Cardiovascular agents
99
3.4
Systemic and haematological agents
97
3.4
Autonomic nervous system agents
87
3.0
Systemic antibiotics
74
2.6
Hormones
71
2.5
Gastrointestinal agents
58
2.0
Anaesthetics
52
1.8
Other chemicals and noxious substances
41
1.4
Anti-infectives / Anti-parasitics
29
1.0
Other gases and vapours
23
0.8
Muscle and respiratory agents
16
0.6
Topical agents
9
0.3
Diuretics
Other and unspecified drugs
5
0.2
606
21.0
*The sum of positive findings is greater than the total number of cases because some cases involved more than one drug or substance.
Source: Unpublished data from HIPE
Use of analgesics in intentional drug overdose presentations to hospital before
and after the withdrawal of distalgesic from the Irish market
The withdrawal of distalgesic from the Irish market resulted in an immediate reduction
in sales to retail pharmacies from 40 million tablets in 2005 to 500,000 tablets in 2006
while there was a 48% increase in sales of other prescription compound analgesics.
The rate of intentional drug overdose (IDO) presentations to hospital involving
distalgesic in 2006–2008 was 84% lower than in the three years before it was
withdrawn (10.0 per 100,000) (Corcoran, et al. 2010). There was a 44% increase in the
rate of IDO presentations involving other prescription compound analgesics but the
magnitude of this rate increase was five times smaller than the magnitude of the
decrease in distalgesic-related IDO presentations. There was a decreasing trend in the
rate of presentations involving any drug containing paracetamol that began in the years
before the withdrawal of distalgesic.
The withdrawal of distalgesic has had positive benefits in terms of IDO presentations to
hospital in Ireland and provides evidence supporting the restriction of availability of
means as a prevention strategy for suicidal behaviour.
Morbidity owing to cocaine use – two studies
In a multicentre cross-sectional study conducted in eight European cities including
Barcelona, Budapest, Dublin, Hamburg, London, Rome, Vienna and Zurich, patterns
of cocaine emergencies were studied (de Millas, et al. 2010). In Dublin the data were
collected through interview or postal questionnaire, and four physicians working in
emergency medicine were interviewed. The data collected recorded the numbers of
86
emergencies in the preceding six months, presenting symptoms, urine toxicology,
treatment provided and post-treatment referral.
The reported frequency differed from city to city, with some emergency departments
having less than one case per half year, and some centres having more than one case
per month. There was an average of eight cases attending emergency departments in
Dublin, comprising less than 1% of all attendees. The adverse signs and symptoms
reported by cocaine users attending emergency departments were associated with the
psychomotor-stimulant or cardiovascular effects of cocaine. In Dublin the most
common psychiatric condition reported was anxiety and the most common physical
symptoms reported were palpitations and leg pain. Urine screens were regularly done
in Dublin and referrals to the addiction services were done by half of those interviewed.
The authors concluded that a closer link between emergency departments and
addiction services would help in guiding problematic drug users towards appropriate
treatment at an earlier stage in their addiction.
Galvin and colleagues (Galvin, et al. 2010) reviewed the hospital and long-term survival
of cocaine-related admissions to an intensive care unit at a Dublin city centre hospital
through a case series review. The authors reviewed all admissions to the intensive
care unit between 2003 and 2007. They identified 19 cocaine-related cases and
followed up discharges to early 2009. Cocaine-related admissions increased from two
in 2004 and one in 2005, to six in 2006 and ten in 2007. The median age of the cases
was 25 years (the range was 17–47), and 78% were male. The median APACHE II
score was 16 (the range was 11–27) and median length of intensive care stay was five
days (the range was 1–16). The diagnosis on admission was coma (8), cardiac arrest
(6), seizure (3) and aspiration injury (2). One case had diabetes, and one had asthma.
Drug toxicology revealed that ten cases had taken cocaine only, and nine cases had
taken cocaine with one or more other drug. The other drugs taken were opioids (5),
benzodiazepines (6), alcohol (4), amphetamines (2) and phencyclidine (2). One case
was a body packer, i.e. he or she had concealed cocaine in his/her body to evade
detection by the Customs authority. All cases required mechanical ventilation. Ten
patients died during their hospital stay: six of the ten cases who took only cocaine died
while in hospital, and four of the nine polydrug users died. A further five had died by
early 2009, a median of 24 months later. One case was untraceable. Four cases were
alive in early 2009. Cocaine toxicity necessitating intensive care is increasingly
common in Dublin. The mortality of emergency cases admitted to intensive case was
high at 52%. These findings may help to inform public attitudes to the serious
outcomes that can occur as a result of cocaine use.
6.3.2
Other topics of interest e.g. psychiatric and somatic co-morbidity, traffic
accidents, pregnancies and children born to drug users
Health and homelessness: the Simon snapshot study
The Simon Communities of Ireland (Simon Communities of Ireland 2010) published a
report on health and homelessness in late 2010. This report presents the findings of a
‘point in time’ survey undertaken between 26 July and 1 August 2010 at all eight Simon
Communities in Ireland. The survey collected data on the profile and health needs of
people using Simon projects and services over a one-week period.
The methods for this study are presented in Section 4.3.1.
Profile of the sample
 78% were male.
 85% were Irish, 6% were British, 5% were Eastern European and 1.4% were
Irish travellers.
 9% were aged between 18 and 25, 21% between 26 and 35 and 54% between
36 and 55.
 51% received a disability allowance and 6% received the old age pension.
87


6.5% were classified as not being habitual residents.
65% were registered as homeless with the local authority.
Physical health
Fifty-six per cent (442) of the respondents had at least one diagnosed physical health
condition. The most common of these were:
 123 cases of cardiovascular disease, including angina, hypertension and
stroke;
 115 cases of infectious disease, including (most commonly) hepatitis C, and
also hepatitis B, HIV, sexually transmitted infection, tuberculosis and urinary
tract infection;
 88 cases of injury, including head injury, broken bones and cuts;
 74 cases of respiratory disease, including asthma, chronic obstructive
pulmonary disease, pneumonia and pleurisy;
 45 cases of neurological disorder, including epilepsy, Parkinson’s disease,
motor neuron disease, spinal muscular atrophy and muscular dystrophy.
Thirty-six per cent of respondents reported one or more undiagnosed physical health
problem.
Diagnosed mental health
Fifty-two per cent (411) of the respondents had at least one diagnosed mental health
condition; 29% reported depression, 9% schizophrenia, 7% panic attacks, 5% social
anxiety disorder, 4% mild cognitive impairment and 3% bi-polar disorder.
Forty-four per cent of respondents reported one or more undiagnosed mental health
conditions.
Co-morbidity
The report outlines the presence of a range of complex needs among the service users
who participated in the research. For example, 28% had at least one diagnosed
physical and at least one diagnosed mental health condition, and 28% were diagnosed
with a mental health condition and reported complications arising from alcohol and/or
drug use.
Suicide and self-harm
Fifteen per cent of respondents reported self-harming episodes at the time of the
survey, 23% reported suicide ideation and 8% had attempted to commit suicide in the
six months prior to the survey.
Trends in alcohol and drug admissions to psychiatric facilities
The annual report on activities of Irish psychiatric units and hospitals in 2009 (Daly and
Walsh 2010) shows that the total number of admissions to inpatient care has continued
to fall.
In 2009, 824 cases were admitted to psychiatric facilities with a drug disorder, of whom
313 were treated for the first time. The report does not present data on drug use and
psychiatric co-morbidity, so it is not possible to determine whether or not these
admissions were appropriate. Figure 6.3.2.1 presents the rates of first admission
between 1991 and 2009 of cases with a diagnosis of drug disorder. The rate was
almost three times higher in 2001 than it was in 1991. Notable dips in the rate occur in
the census years 1996, 2002 and 2006, and can be partly explained by the increased
population figures used as the denominator in calculating the rate for those years.
The overall increase in the rate of drug-related first admissions between 1991 and
2001 reflects the increase in problem drug use in Ireland and its burden on the
psychiatric services. The overall decrease in the rate since 2001 possibly reflects an
increase in the provision of community-based specialised addiction services during this
period. The increased rate in 2005 may be accounted for by the use of the 2002
census figure in calculating the rate. The decrease to 5.9 in 2006 reflects the new
88
census figure used as denominator. The rate increased in 2008 and 2009. Of the 847
discharges with a drug disorder, 50% spent six days or more in hospital.
Rate per 100,000 population
9
8
7
6
5
4
3
2
1
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Drug disorder 3.5 4.1 4.7 5.6 7.5 6.7 6.5 7.2 7.9 7.8 8.4 6.3 6.1 6.7 7.9 5.9 6.3 6.8 7.4
Figure 6.3.2.1. Rates of psychiatric first admission of cases with a diagnosis of drug disorder
(using the ICD-10 three-character categories) per 100,000 of the population in Ireland, NPIRS 1991–
2009
Source: (Daly and Walsh 2010)
Prevalence of adult ADHD in psychiatric clinics in north Dublin
Syed and colleague (Syed, et al. 2010) estimated the prevalence of attention-deficit
hyperactivity disorder (ADHD) in adults attending outpatient psychiatric services. Two
hundred and sixty-five adults aged 18 to 65 years, attending five out-patient public
clinics in north Dublin, were asked to complete the World Health Organization’s Adult
Self-Report Scale VI.I; 243 (92%) agreed to complete the scale. The scale contains six
items measuring inattention or over-activity; each question is answered using a fivepoint scale ranging from never to very often. Where a participant answers four or more
of the six questions with ‘sometimes’, ‘often’ or ‘very often’, this denotes a case.
Demographic and clinical data were also recorded using a self-completion
questionnaire and the medical record.
The average age of the respondents was 42.5 years and 56% were women. Twentyfour per cent of respondents were diagnosed as having ADHD, and 69% of these were
male, the average age was 42.1 years, and almost 11% had a diagnosis of substance
abuse (alcohol and other drugs). When compared to patients without ADHD, those
diagnosed with ADHD were significantly more likely not to complete second-level
education, to have had ADHD diagnosis or ADHD symptoms as children, a forensic
history, current personality disorder diagnosis and a higher rate of prescribed
benzodiazepine use. They were no more likely to be dissatisfied with the service,
heavy users of the service, or diagnosed with substance abuse.
The data indicate that ADHD is common among adults treated for mental illness. None
of the patients had a recorded diagnosis of ADHD, indicating significant underdiagnosis of this manageable condition.
Mental illness and alcohol and other drug use
Substance dependence and other mental illnesses co-exist in a proportion of patients
attending health services and two recent Irish studies have attempted to estimate and
describe the phenomenon.
Lyne and colleagues (Lyne, et al. 2011) reviewed the records of patients presenting
with co-morbid psychiatric diagnoses and drug use at a 12-bed alcohol treatment unit
in a psychiatric teaching hospital in Dublin between 1995 and 2006. Patients were
included if they were aged 44 years or under, had remained in hospital for more than
28 days, and had a diagnosis of alcohol dependence.
89
The review of 465 records revealed that 38.9% of patients had used drugs other than
alcohol during their life and 34.2% had a documented history of a co-morbid psychiatric
diagnosis. The most commonly reported substances were cannabis (26.4%), cocaine
(17.1%), and ecstasy (12.5%); just under 10% reported use of benzodiazepines or
other sedatives and just under 6% had used heroin. The disease-specific rates for the
465 cases were depressive disorder (25.3%), anxiety disorder (3.9%), bipolar affective
disorder (2.8%) and psychotic disorder (2.2%). A small proportion (3.7%) of patients
had two or more psychiatric diagnoses alongside their alcohol dependence. Forty-eight
(10.3%) patients had a documented history of deliberate self-harm, of whom 29 had a
psychiatric diagnosis as well as alcohol dependence.
The median age of the study population was 37 years and the age range was 17–44
years. Just over three-fifths (61.1%) of patients were men, 203 (44.3%) of the patients
had never married, and 38 (8.3%) were separated or divorced. The proportions of
women with a history of depressive disorder, eating disorder or deliberate self-harm
were significantly higher than those for men. The proportion of men with psychotic
disorder was marginally higher than that of women. Deliberate self-harm was
associated with lifetime drug (excluding alcohol) use. Ecstasy users were more likely to
have a diagnosis of depression.
Skinner and colleagues (Skinner, et al. 2011) explored the relationship between
cannabis use and self-reported dimensions of psychosis in a population of university
students presenting for any reason to primary care.
Fifteen thousand students were enrolled in undergraduate or postgraduate courses at
the National University of Ireland, Galway, in 2008. One thousand and forty-nine (7%)
students attended the Student Health Unit between April and October of that year and
they completed self-report questionnaires on:
 demographic profile,
 history of mental illness,
 alcohol and other drug misuse,
 non-clinical dimensions of psychosis [Community Assessment of Psychic
Experiences (CAPE)], and
 anxiety and depression [Hospital Anxiety and Depression Scale (HADS)].
The respondents may not be representative of the third-level student population. The
average age of the respondents was 21.2 years (range 17–54); 82% were women;
94% were Irish; and 96% were single. Sixteen per cent sought professional help for
emotional or psychiatric problems, 23% reported a family history of mental illness, and
almost 5% reported a family history of psychotic illness.
Respondents reported drinking an average of 9.4 units (range 0–120) of alcohol per
week and an average of 5.9 units (range 0–35) per sitting. Forty per cent (423) had
smoked cannabis at least once in their lives, of whom 327 reported use between 1 and
30 times, and 86 reported use 30 or more times. The average age at first use of
cannabis was almost 17 years (range 10–40). The rates of lifetime use of other drugs
were ecstasy (6.9%), cocaine (5.8%), magic mushrooms (5.1%), LSD (2.1%) and
heroin (0.1%).
Twenty-one per cent had HADS scores of between 8 and 10 (borderline abnormal
level) on the anxiety subscale, and 15% had scores of 11 or above (abnormal level).
Just under 3% reported borderline abnormal level on the depressive subscale and 1%
reported abnormal level. The average weighted CAPE frequency score for negative
symptoms was 1.57 (range 1–4), and for positive symptoms 1.29 (range 1–3). The
higher HADS anxiety scores were associated with a personal history of mental illness,
a family history of psychiatric disorder and being female. The higher HADS depression
scores were associated with a personal history of mental illness.
90
The CAPE positive psychotic symptom scores were associated with a personal history
of mental illness and a family history of psychiatric disorder, and with being younger
and male. The CAPE negative psychotic symptom scores were associated with a
personal history of mental illness and a family history of psychiatric disorder. The
CAPE depressive symptom scores were associated with a personal history of mental
illness, a family history of psychiatric disorder and being female.
After controlling for the effects of personal history of mental illness, family history of
psychiatric disorder, age and gender, the CAPE positive and negative psychotic
symptom scores were associated with high-frequency cannabis use. In addition, the
CAPE negative psychotic symptom scores and depressive symptom scores were
associated with low-frequency cannabis use.
After further controlling for frequency of cannabis use, it was found that the earlier the
age at which a person started cannabis use, the more positive psychotic symptoms
they experienced.
These findings support the hypotheses that cannabis use increases the risk of
developing psychotic symptoms and that this risk increases further in individuals who
use cannabis more heavily and start use at a younger age.
Psychiatric presentations and physical complications linked with ‘head shop’
products
Several cases have been reported in peer review journals of psychiatric illness and
physical complications as a result of using substances purchased in head shops in
Ireland.
Butylone and MDPV
Fröhlich and colleagues (Fröhlich, et al. 2011) report the case of a young man who
presented with acute psychosis and subsequently developed hepatic failure following
ingestion of Butylone and MDPV (methylenedioxypyrovalerone). These substances
were sold in head shops in Ireland and on line until 23 August 2010. The patient was a
28-year-old male suffering from bipolar affective disorder but otherwise healthy.
Following ingestion of 12 tablets he had a seizure. On arrival at hospital his
neurological assessment (GCS) was 5 out of a possible 15, heart rate was 190 beats
per minute, systolic blood pressure 230 mmHg, temperature 39.5°C and he was
sweating profusely. He was treated in the intensive care unit, with cooling (to reduce
his temperature), mechanical ventilation (to assist his breathing), labetalol (to reduce
his blood pressure) and phenytoin (to manage his seizures). Urinary and serum
screens for drugs did not reveal any evidence of MDMA, cocaine, paracetamol, or
salicylates. The tablets taken were examined and found to contain Butylone and
MDPV. After ten hours the patient’s neurological and respiratory status were normal.
On day two, he developed Rhabdomyolysis, which is a condition in which damaged
skeletal muscle tissue breaks down rapidly and this condition is associated with
stimulant use. This was treated conservatively (possibly with intravenous fluids).
Unexpectedly, between day two and day three, his liver function tests indicated that he
had developed acute liver failure. Following treatment for three days with Nacetylcysteine infusion (normally used as a treatment for paracetamol overdose), liver
tests showed his liver function was slowly returning to normal. On day four, the patient
was discharged from the intensive care to psychiatric care where he received treatment
for a recurrence of his psychosis, thought to be triggered by consumption of Butylone
and MDPV. This is the first case report associating these compounds with acute liver
failure. There is no record in the literature of these compounds being associated with
liver injury. However, the liver is known to be a target organ for MDMA toxicity, possibly
owing to damage to specific part of the cells that make up muscle tissue.
The recreational use of a variety of psychoactive drugs is increasing. The effects of
these drugs mimic amphetamine ingestion but little is known about their dosing or
safety profile. The authors support the need for regulation of these substances.
91
Methylone
Uhoegbu and colleagues (Uhoegbu, et al. 2011) reported two cases of acute onset of
and rapid recovery from psychotic symptoms, the first after eating a head shop product
and the second after injecting it; the product probably contained methylone. Common
psychotic symptoms included hallucinations, delusions, and disturbed thoughts.
A 30-year-old woman with no past psychiatric history attended a Dublin emergency
department with a 24-hour history of restlessness, irritability, paranoid delusions and a
maculo-papular rash on the lower third of her right thigh and on the upper third of both
thighs. Physical examination revealed raised and fluctuating blood pressure and pulse
rates with peaks of 160/100mmHg and 120bpm respectively. Her brain scan and
lumbar puncture (spinal fluid) were normal. Her urine test was negative for ‘common’
illicit substances.
A 29-year-old man of no fixed abode and a long history of injecting drug use attended
the same emergency department with signs of a recent onset of a florid psychotic
episode (evidenced by hallucinations and delusions). On examination, he was quite
agitated and described hearing voices and seeing visual hallucinations. He had
delusions (beliefs not backed by reality) and also reported passing thoughts about
suicide. He also described some sub-clinical symptoms of depression. There were no
abnormalities identified during the physical examination, and the only abnormal
laboratory findings were urine tests that were positive for opiates and benzodiazepines.
He was already attending the addiction services for methadone maintenance therapy.
He had no past history of psychotic or mood disorder.
Both cases were admitted to hospital for five days and were treated with an atypical
antipsychotic and a benzodiazepine. Their symptoms settled within 48 hours of
admission.
Whack
In June 2010 the NPIC informed the HSE’s Department of Public Health of significant
adverse effects associated with a recreational drug called Whack, which was being
sold in headshops. The HSE subsequently issued a warning to the general public
about the drug. Between 30 May and 16 June 2010 the centre was contacted about 49
patients who had suffered adverse effects after taking Whack. They presented with
sympathomimetic features of tachycardia and hypertension, as well as agitation and
severe psychotic reactions with delusions of parasitosis and hallucinations, persisting
for up to 5 days.
The Forensic Science Laboratory has since analysed this product and found it to
contain two active ingredients. The first, fluorotropacocaine, is a drug of lower potency
than the parent compound, cocaine. The second compound was tentatively identified
as desoxypipradrol (there is no current external reference standard so a best library
match was used). This is an analogue of pipradrol, which is a central nervous system
stimulant developed in the 1950s. It is likely that the severe, long-acting effects
associated with Whack are due to this agent, as pipradrol has been previously
associated with psychotic reactions and insomnia.
El-Higaya and colleagues (El-Higaya, et al. 2011) presented two case studies of men
who developed acute psychotic states after using Whack. There was a striking
similarity between symptoms in the two cases, with initial euphoria and disinhibition
followed by severe anxiety, insomnia, depressed mood, restlessness, agitation, pacing
and psychosis. These symptoms persisted for 7–10 days after using Whack. Both men
required inpatient treatment but responded well to atypical antipsychotic agents. This is
the first published case series relating to this psychoactive substance in Ireland.
Benzylpiperazine
Tully and colleagues (Tully, et al. 2011) described the case of a 48-year-old man with
schizophrenia who developed an acute delirium or confusion secondary to use of
92
benzylpiperazine, a psychotropic compound widely available in head shops. This is the
first documented case of delirium owing to benzylpiperazine use in Ireland.
Investigation of his delirium unearthed a temporal meningioma, which appears to have
been an unrelated or supplementary finding.
Butylone
A letter to the editor of the Irish Medical Journal (Herbert and Tracey 2010) reported two
cases of people who sought medical assistance after taking butylone (sold as London
Underground Doves). The first case was that of a 25-year-old woman who experienced
dilated pupils, facial flushing and tachycardia (fast pulse). The second was that of a 37year-old man who experienced vomiting, abdominal pain, palpitations and chest pain.
Both cases recovered following symptomatic treatment.
Mephedrone
Nicholson and colleagues (Nicholson, et al. 2010) presented a case study of a 19-yearold man who came to hospital with crushing chest pain 20 hours after eating a gram of
plant food containing mephedrone. His history and urinalysis indicated that he had not
taken other drugs. His electrocardiograph (ECG) showed an abnormal heart rhythm
(ST elevation) and his MRI confirmed the abnormal heart rhythm and showed swelling
of the heart muscle. The patient recovered after five days in hospital. The authors
reported that it is not clear how mephedrone induces inflammation of the heart but it is
thought that such damage to the heart could cause death; it is speculated that
mephedrone has caused a number of deaths in the United Kingdom and confirmed that
it has caused one death in Sweden.
6.4
Drug-related deaths and mortality of drug users
6.4.1
Drug-induced deaths (overdoses/poisonings)
In 2009, the number of deaths owing to poisoning recorded in Ireland by the NDRDI (as
per Selection D) decreased slightly, to 203 deaths from 211 in 2008 (Table 6.4.1.1,
also see Standard Table 5). This is the first decreased in the number of deaths owing
to poisoning since 2003. It should be noted that annual data previously reported have
changed as the database has been updated as new information has become available.
Table 6.4.1.1 Poisonings (Selection D) by year, NDRDI, 1999 to 2009 (N=1681)
Selection
D
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
115
113
109
127
109
128
173
188
205
212
203
Source: Unpublished data NDRDI
In 2009, the mean age of those dying from poisoning was 35 years and the majority of
individuals were aged between 20 and 39 years of age (140, 70%). The majority were
male (158, 77.8%), although there was a difference between the mean age of males
(34 years) and of females (38 years). This pattern is similar to findings from previous
years and also reflects international trends (see Standard Table 5).
Opiates continued to be associated with the majority of fatal overdoses in 2009, with
180 (88.7%) deaths being associated with opiates alone or with another drug. This
percentage is higher than reported for previous years. The number of deaths where
cocaine was implicated, alone or with another drug, decreased again in 2009. In 2008,
cocaine was implicated in 58 deaths while in 2009, it was implicated in 52 deaths by
poisoning in 2009.
Of the 203 cases of poisoning recorded in 2009, heroin or unspecified opiates alone
accounted for 50 (24.6%) cases. Deaths attributable to polysubstances increased:
more than half of all deaths owing to poisoning (125, 61.6%) were attributable to
polysubstances, including an opiate, which is higher than reported in previous years.
93
The trends in drug-related deaths in 2009 are reflected in drug treatment trends (see
TDI data and Section 5.6), which show an increase in the number of cases treated for
problem opiate use and a slight decrease in the number of cases treated for problem
cocaine use.
Alcohol and other drugs, including benzodiazepines, non-benzodiazepine sedatives,
antidepressants, other prescription medication and over-the-counter medication,
continue to contribute significantly to the burden of drug-related deaths in Ireland but
are not reported as part of Selection D (Health Research Board 2011).
Benzodiazepine-related deaths
Data on poisoning deaths where a benzodiazepine was implicated as recorded by the
NDRDI between 1998 and 2007 were published in December 2010 (Bellerose, et al.
2010). This was the first time that treatment data from the NDTRS and the NDRDI was
presented together in a Trends Series paper, providing a more complete picture of
problem benzodiazepine use and its consequences (for detail, see Chapter 5.6 above).
Alcohol-related deaths
The NDRDI published its third trend paper, describing, for the first time, trends in
alcohol-related deaths and deaths among people who were alcohol dependent in
Ireland for the years 2004−2008 (Lyons, Dr Suzi, et al. 2011) .
Alcohol-related poisonings
Between 2004 and 2008, 672 poisoning deaths in which alcohol was implicated (alone
or in conjunction with other drugs) were recorded (Table 6.4.1.2). This makes alcohol
the drug most frequently implicated in all fatal poisonings in Ireland in the five-year
period. Most of those who died were male. The highest number of deaths was
recorded in 2007 (170). The median age of those who died of alcohol-only poisoning
was 48 years, that of those who died of alcohol polysubstance (alcohol plus other
substance/s) poisoning was 41 years.
Table 6.4.1.2 Alcohol-related poisoning deaths (NDRDI 2004–2008) (N = 671)
2004
2005
2006
Total
125
116
111
Alcohol only (n = 331)
Alcohol polysubstance (n = 341)
61
64
51
65
54
57
2007
170
2008
150
85
85
80
70
Source (Lyons, Dr Suzi, et al. 2011)
Just over half (50.7%) of all alcohol-related poisonings involved another substance.
Most commonly implicated along with alcohol were benzodiazepines (61.3%) and
opiates (including heroin and methadone) (55.7%) (Table 6.4.1.3).
Table 6.4.1.3 Additional drugs involved in alcohol polysubstance poisoning deaths (NDRDI 2004–
2008) (N = 341)
%
All alcohol polysubstance poisonings*
100.0
Benzodiazepines
Antidepressants
Heroin
Other opiates†
Other prescription medication
Methadone
Cocaine
61.3
23.5
22.9
21.4
15.5
11.4
9.1
Other‡
8.8
* Numbers and percentages in columns do not add up to totals shown in this row because individual deaths are attributable to alcohol
and one or more other drug(s) or substance.
† Excludes heroin and methadone.
‡ Includes other illicit and licit drugs such as amphetamines, hallucinogens, volatile inhalants, cannabis or non-opiate analgesia.
Source (Lyons, Dr Suzi, et al. 2011)
All NDRDI-recorded poisoning deaths
Table 6.4.1.4 presents data on alcohol poisonings alongside data on poisonings from
all other substances in order to compare the contribution of alcohol to fatal poisonings
94
nationally. Alcohol was implicated in 40.7% of all poisonings, making it the drug most
frequently implicated in fatal poisonings in Ireland for the period 2004–2008.
Table 6.4.1.4 Drugs involved in all poisoning deaths in Ireland (NDRDI 2004–2008) (N=1,650)
Positive findings
%
Alcohol
40.7
Benzodiazepines
31.1
Heroin
18.7
Methadone
16.7
Antidepressants
16.7
Other prescription drugs
14.5
Cocaine
14.0
Other opiates†
17.3
Non-opiate analgesic
5.0
MDMA
3.3
Other‡
3.1
* Percentages do not add up to total shown in this row because individual deaths may be attributable to more than one drug or
substance.
† Excludes heroin and methadone.
‡ Includes other illicit and licit drugs such as amphetamines, hallucinogens, volatile inhalants or cannabis.
Source (Lyons, Dr Suzi, et al. 2011)
The analysis showed clearly the burden of premature mortality as many of those who
died were still in their prime, aged between 40 and 59 years. Going forward, the
NDRDI will be able to measure any changes in public health policy on alcohol-related
mortality in the Irish population.
Heroin drought
In early 2011 at least six fatal heroin overdoses were reported by the Irish media. This
was reputed to be caused by a drought of heroin in December 2010, followed by the
arrival of a batch ‘high quality’ heroin into the country(Holland 2011, February 15,
O'Keefe 2010, December 16). A similar drought had been reported by the media in the
UK around the same period (Boyce 2011) (Attewill 2011, 31 January). Harm-reduction
agencies issued warnings and advice to their clients about the risks of loss of tolerance
and overdose during this period. Research into a heroin drought in Australia early in
this century showed increased use of other substances especially cocaine during the
drought (Weatherburn, et al. 2003). The true extent, pattern and full impact of this
drought on poisoning deaths in Ireland will be reported in future annual figures from the
NDRDI.
National Overdose Prevention Strategy
Currently a national overdose prevention strategy is being developed by a working
group comprising of the Department of Health, the HSE, the HRB and the National
Advisory Committee on Drugs (Personal Communication, S Lyons Health Research
Board). The aim of the working group is to identify evidence based interventions for
preventing drug-related deaths and deaths among drug users. The group will then
advise on the most appropriate of these interventions for the Irish context.
The terms of reference were to:
 consider National Drug-Related Deaths Index reports;
 set targets for reduction of drug deaths;
 list possible components of an overdose prevention strategy; and
 make recommendations on how different elements of the strategy could be
operationalised.
The report is not yet finalised.
6.4.2
Mortality and causes of deaths among drug users (mortality cohort studies)
No information available.
95
6.4.3
Specific causes of mortality indirectly related to drug use (e.g. HIV/AIDS
and HCV related to IDU, suicides, accidents)
Specific causes of mortality indirectly related to drug use
Between 1998 and 2008 there were 1630 non-poisoning deaths among drug users in
Ireland recorded by the NDRDI (Table 6.4.3.1) (Health Research Board 2011). A drug
user is defined in this analysis as an individual who has a history of drug dependency
or of non-dependent abuse of drugs and/or other substances.
Table 6.4.3.1 Drug-related deaths, by year of death, NDRDI 1998–2008 (N=4,064)
Non-poisoning (n=1630)
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
64
84
79
100
127
111
162
203
232
237
231
Source: NDRDI (Health Research Board 2011)
Of the 1,468 cases with a known cause of death, 58.3% (856) were due to trauma and
41.7% (612) were due to medical causes (Figure 6.4.3.1).
250
200
150
Medical
100
Trauma
50
0
Medical
Trauma
1998
11
40
1999
27
41
2000
19
51
2001
24
60
2002
45
67
2003
30
55
2004
55
89
2005
68
115
2006
102
123
2007
111
114
2008
120
101
Figure 6.4.3.1 Deaths due to medical or traumatic causes among drug users, NDRDI, 1998 to 2008
(N = 1630)
Source: NDRDI (Health Research Board 2011)
Deaths owing to trauma 2008
The annual number of deaths owing to trauma had been decreasing slightly since 2006
when 123 cases were reported to 101 cases in 2008 (Figure 6.4.3.1). These figures
may be revised when new data becomes available.
Sixty-one (61%) of those who died from traumatic causes in 2008 were aged between
20 and 34years. The median age was 28 years. As reported in previous years, the
majority were male (88, 87%).
The most common causes of death due to trauma were hanging and drowning.
Deaths owing to medical causes 2008
The annual number of deaths owing to medical causes rose fairly steadily over the
reporting period, from 11 in 1998 to 120 in 2008, when it exceeded the number of
deaths owing to trauma for the first time (Figure 6.4.3.1). The majority of those who
died from medical causes in 2008 were aged between 30 and 49 years. The median
age was 42 years. Three-quarters (352, 76%) of those who died in 2008 were male.
The most common medical causes of death in 2008 were cardiac events (25, 21%),
respiratory infections (16, 13%) and liver disease (12, 10%). These percentages are
similar to those reported in previous years.
Annual report of the Poison Information Centre of Ireland
According to its annual report for 2010 (Poison Information Centre of Ireland 2011), the
NPIC received 11,589 enquiries, a decrease of 1.6% from 2009. Of these, 1,904 were
dealt with by the NPIS in the UK and are not included in the analysis presented in the
report. Of the 9,685 calls answered by the NPIC, 9,330 (96.3%) were about human
96
toxicology. The remaining calls concerned poisoning in animals (0.7%) and nonemergency requests for information (2.9%).
The most frequent enquiries were from general practitioners/general practitioner co-ops
(38.2%), hospitals (33.2%) and members of the public (22.9%). The other sources of
enquiries were community pharmacists, carers, vets, industry/manufacturers, schools,
emergency services, media, and government agencies.
Half of the enquiries about cases of poisoning in humans concerned children under 10
years of age and males outnumbered females in this age group. Nearly two thirds
(n=2,744, 29.4%) of enquiries were about adults (>20 years), with a predominance of
females in this age group.
The main agents involved in these cases were household products, laundry products,
particularly liquid detergent capsules, and cleaning products. The majority (93.4%) of
all human poisoning incidents occurred in the home or a domestic setting.
More than half (59.6%) of the human cases were suspected accidental poisonings,
25.1% were intentional poisoning or recreational abuse, 12.2% were therapeutic errors
and 3.2% had another or unknown intent.
The enquiries about human toxicology involved 15,164 agents, mainly drugs, industrial
chemicals and household products. The most common enquiry concerned substances
containing paracetamol (1,302), and the second most common agent was ibuprofen
(454). Only a small proportion of cases (361, 3.9%) were followed up. Although most
recovered completely, 24 cases suffered adverse effects, a further 12 cases died, while
the outcome of 34 cases could not be determined. One of these fatalities may not have
been caused by poisoning (post mortem examination to be carried out); the others
were all cases of deliberate self-poisoning or drug/substance abuse.
97
7.
Responses to Health Correlates and Consequences
7.1
Introduction
This chapter presents new data on preventing drug-related mortality, the management
of blood-borne viral infections, and responses to co-morbidity. The public, voluntary
and community sector institutions that have been engaged in the various initiatives
described in the following sections are briefly described here.
The Ana Liffey Drug Project (ALDP) is a voluntary organisation offering a lowthreshold harm-reduction service in north inner-city Dublin. It works with people
experiencing addiction, to minimise the harm that problematic drug use causes them,
their families and the wider community. It provides a range of services including a dropin service, outreach service, family care and case management service, peer-support
and literacy tutoring.
The Bluebell Addiction Advisory Group (BAAG) was established, under the
auspices of the Canal Communities Local Drugs Task Force, in inner-city Dublin, in
October 2002. Its main objective is to provide strategic local responses to serious drug
use in partnership with the community. Services include outreach, education and
prevention, and family support.
The Health Service Executive (HSE) is responsible for managing and delivering
health and personal social services in Ireland. It supports numerous responses to the
health correlates and consequences of problematic drug use.
The Pharmaceutical Society of Ireland (PSI) is an independent statutory body,
established by the Pharmacy Act 2007, charged with the effective regulation of
pharmacy services in Ireland, including supervising compliance.
7.2
Prevention of drug-related emergencies and reduction of drugrelated deaths
Use of analgesics in intentional drug overdose presentations to hospital before
and after the withdrawal of distalgesic from the Irish market
Distalgesic, the prescription-only analgesic compound of paracetamol (325 mg) and
dextropropoxyphene (32.5 mg), known as co-proxamol in the UK, was withdrawn from
the Irish market as of January 2006. Corcoran and colleagues (Corcoran, et al. 2010)
evaluated the impact of the withdrawal of distalgesic in terms of non-fatal intentional
drug overdose presentations to hospital emergency departments nationally. A total of
42,849 non-fatal intentional drug overdose presentations to 37 of the 40 hospital
emergency departments operating in Ireland in 2003–2008 were recorded, using
standardised procedures. The average number of cases was 7,142 (range 6,642 to
7,692). Data on sales of drugs containing paracetamo to retail pharmacies for the
period 1998–2008 were obtained.
Women accounted for 61.2% of all of non-fatal intentional drug overdose presentations,
a proportion that did not vary by year. The total, male and female annual rates
respectively of intentional drug overdose presentations to hospital emergency
departments per 100,000 population were 188.4 (95% CI = 186.6-190.1), 143.5 (95%
CI = 141.3-145.7) and 234.3 (95% CI = 231.5-237.0). After adjustment for age, female
gender was associated with a 60% higher rate of intentional drug overdose
presentation (IRR = 1.60, 95% CI = 1.57-1.63). At least one drug containing
paracetamol was involved in 13,066 (30.5%) of the intentional drug overdose
presentations. The total, male and female annual rates respectively of intentional drug
overdose presentations to hospital involving paracetamol were 57.0 (95% CI = 56.057.9), 35.4 (95% CI = 34.3-36.5) and 79.1 (95% CI = 77.5-80.7) per 100,000
population. After adjustment for age, female gender was associated with more than
98
double the rate of paracetamol-related intentional drug overdose presentations (IRR =
2.21, 95% CI = 2.13-2.28).
The national rate of intentional drug overdose presentations to hospital decreased over
the study period. The rate was 212.3 per 100,000 in 2003 and fell annually by 6.7%
(95% CI = 5.8-7.6%) to 173.6 in 2006. Between 2007 and 2008, the rate increased
from 175.3 to 187.2 per 100,000, an increase of 7.0% (95% CI = 3.8-10.3%) after
adjustment for age. This trend was also evident for intentional drug overdose
presentations involving a drug containing paracetamol. The rate was 64.3 per 100,000
in 2003 and also fell annually by 6.7% (95% CI = 5.1-8.3%) to 51.9 in 2006. Between
2007 and 2008, the rate increased from 51.2 to 55.1 per 100,000, an increase of 6.5%
(95% CI = 0.6-12.6%) after adjustment for age.
Sales to retail pharmacies of distalgesic, other prescription compound analgesics,
solpadeine and other drugs containing paracetamol increased by 4%–6% per year over
the eight years (1998–2005) before distalgesic was withdrawn from the Irish market. In
2005, approximately 40 million tablets of distalgesic were sold to pharmacies. This fell
to 500,000 in 2006, to approximately 2,000 in 2007 and to none in 2008. Between 2005
and 2006, there was a 48% jump in sales of other prescription compound analgesics,
an 11% increase in sales of solpadeine and a 22% increase in sales of other
paracetamol-containing medicines.
Of the 42,849 recorded intentional drug overdose presentations, distalgesic was one of
the drugs taken in 1,312 (3.1%) overdose acts. The involvement of distalgesic in
intentional drug overdose acts differed by gender (Chi-square = 12.13, df = 1, p <
0.001), age (Chi-square = 37.64, df = 4, p < 0.001) and year (Chi-square = 635.38, df =
5, p < 0.001). Distalgesic was more common in female intentional drug overdose acts
and was less common with increasing age. In the three years before distalgesic was
withdrawn, it was involved in almost 400 presentations annually, approximately 5% of
all intentional drug overdose presentations.
The three years following withdrawal of distalgesic saw sharp reductions in the
numbers and proportions of intentional drug overdose presentations involving
distalgesic. A similar pattern was observed when distalgesic was considered as a
proportion of all paracetamol-related intentional drug overdose presentations. The drug
was involved in 16% of paracetamol-related drug overdose acts in 2003–2005 but this
declined sharply in line with the distalgesic withdrawal. The age-standardised rate of
intentional drug overdose presentations to hospital involving distalgesic was 10 per
100,000 between 2003 and 2005, and in each of the three post-withdrawal years, the
rate fell to 2.7 (95% CI = 2.2-3.2) per 100,000 in 2006, 1.6 (95% CI = 1.2-2.0) per
100,000 in 2007 and 0.6 (95% CI = 0.4-0.9) per 100,000 in 2008. In contrast, the rate
of intentional drug overdose presentations involving the other prescription compound
analgesics was approximately 4 per 100,000 in 2003–2005, rising to 5.0 (95% CI = 4.35.7), 6.4 (95% CI = 5.6-7.2) and 6.4 (95% CI = 5.6-7.1) per 100,000 in 2006, 2007 and
2008 respectively. There was no trend evident in the rate of intentional drug overdose
presentations involving solpadeine. The rate of intentional drug overdose presentations
to hospital involving distalgesic in 2006–2008 was 83.5% lower than it had been in the
three years before it was withdrawn. This decrease was graded across the three years.
Compared to 2003–2005, the rate of distalgesic-related intentional drug overdose
presentations was 72.3% (95% CI = 66.7-76.9%) lower in 2006, 84.0% (95% CI = 79.887.3%) lower in 2007 and 93.8% (95% CI = 91.0-95.7%) lower in 2008. The rate of
intentional drug overdose presentations involving the other prescription compound
analgesics was 43.5% higher in 2006–2008 than in 2003–2005. The increase were
somewhat graded – 22.0% (95% CI = 4.4-42.5%) higher in 2006, 54.5% (95% CI =
34.0-78.3%) higher in 2007 and 53.3% (95% CI = 33.0- 76.7%) higher in 2008. The
overall rate of presentations involving any drug containing paracetamol was 16.4%
lower in 2006–2008 than in 2003–2005. The median number of distalgesic tablets
taken in intentional drug overdose presentations involving the drug was 20
(interquartile (IQ) range = 10–30), with men, on average, taking more distalgesic
99
tablets in IDO acts than women (Mann-Whitney U = 117,207, p < 0.001; Male median
(IQ range) = 20 (12-36); Female median (IQ range) = 18 (10-28
The withdrawal of distalgesic from the Irish market resulted in an immediate reduction
in sales to retail pharmacies from 40 million tablets in 2005 to 500,000 tablets in 2006
while there was a 48% increase in sales of other prescription compound analgesics.
The rate of intentional drug overdose presentations to hospital involving distalgesic in
2006–2008 was 84% lower than in the three years before it was withdrawn (10.0 per
100,000). There was a 44% increase in the rate of intentional drug overdose
presentations involving other prescription compound analgesics but the magnitude of
this rate increase was five times smaller than the magnitude of the decrease in
distalgesic-related intentional drug overdose presentations. There was a decreasing
trend in the rate of presentations involving any paracetamol-containing drug that began
in the years before the distalgesic withdrawal.
The withdrawal of distalgesic has had positive benefits in terms of intentional drug
overdose presentations to hospital in Ireland and provides evidence supporting the
restriction of availability of means as a prevention strategy for suicidal behaviour.
Pharmacy guidelines on safe supply of codeine-based products
The Pharmacy Act 2007 and the Regulation of Retail Pharmacy Businesses
Regulations 2008 require that all codeine-based products be dispensed under the
supervision of a pharmacist, and that individuals in receipt of the product should
receive appropriate counselling. In May 2010, the Pharmaceutical Society of Ireland
published guidelines on the safe dispensing of non-prescription products containing
codeine (The Pharmaceutical Society of Ireland 2010). Codeine is an opiate-based
analgesic which is controlled under the Misuse of Drugs Acts 1977 and 1984 and is
most often sold as a combination drug in non-prescription medication. It is well
established that codeine-based medications have the potential to be abused and, if
used for long periods, psychological and physical dependence can occur. Withdrawal
of codeine in individuals who have taken excess doses over long periods of time may
result in restlessness and irritability.
Codeine is used in many popular over-the-counter painkillers (e.g. Solpadeine), often in
combination with other non-prescription painkillers such as paracetamol or ibuprofen
(e.g. Nurofen Plus). Certain cough medicines and flu remedies also contain codeine
(Irish Medicines Board 2011). An individual who takes excess amounts of a
combination drug is at risk of the toxic effects of both drugs.
The guide aims to ensure the safe supply of medicines and to support pharmacists in
their legal obligation to dispense non-prescription products containing codeine. The
main points in the guide are:





Products containing codeine cannot be displayed in the ‘self-selection’ area of the
pharmacy.
Codeine-based products should only be dispensed under the supervision of the
pharmacist, who should be in a position to consult with the patient so as to
determine the appropriateness of the request. Each repeated request should have
a separate consultation.
Education should be provided to the individual in receipt of codeine-based
products, including dosage regime, overdose risk, drug interactions, side effects
and safe storage.
Pharmacists should be alert to the possibility that some patients may request
codeine-based medicines for symptoms that are in fact secondary to excess
codeine consumption.
Products containing codeine are a second-line treatment and should only be
considered when the likes of paracetamol, aspirin and ibuprofen have not been
successful in pain management.
100



7.3
It is the responsibility of the pharmacist to manage the supply and ensure suitable
controls are in place for the management of dispensing codeine-based products.
If a pharmacist suspects that an individual is abusing or dependent on codeine,
she/he is obliged to make a reasonable attempt to facilitate the individual in
accessing treatment services.
Advertising medication containing codeine is prohibited; this includes window
displays, in-pharmacy promotions, promotional displays and leaflets and stickers.
Prevention and treatment of drug-related infectious diseases
Barriers to and facilitators of hepatitis C care
Hepatitis C infection is common among injecting drug users (IDUs), yet access to
hepatitis C care, particularly treatment, is suboptimal. There has been little in-depth
study of IDUs’ experiences of what enables or prevents them engaging at every level of
hepatitis C care, including testing, follow-up, management and treatment processes.
A qualitative study aimed to explore these issues with current and former IDUs in the
greater Dublin area (Swan, et al. 2010). Between September 2007 and September
2008 in-depth interviews were conducted with 36 service users across a range of
primary and secondary care services, including two addiction clinics, a general
practice, a community drop-in centre, two hepatology clinics, and an infectious
diseases clinic. Interviews were analysed using a grounded theory approach.
Of the 36 participants interviewed, 28 were men and eight were women. They ranged
in age from 24 to 54 years, with a median age of 32 years. The median reported age at
first injecting drugs was 18.5 years (range 14–29 years). Of the 28 who reported their
main problem drug, 79% reported heroin and 21% cocaine. Thirty-three (91%)
participants reported testing positive for hepatitis C, of whom four (11%) reported
HIV/HCV co-infection.
Among the factors influencing access to and uptake of HCV care were:
 perceptions that every injector had this invisible infection (hepatitis C) and that its
effects were not as serious as those of HIV;
 perceptions that the investigations and treatments for hepatitis C were more severe
than the infection itself;
 use of coping strategies, such as blocking awareness, escape, support and positive
thinking, to deal with fears about the future effects of hepatitis C, or anxieties about
investigations or treatment;
 the quality of relationships with health care providers;
 contact with services, encouraging and caring doctors and nurses, family ties,
recovery from addiction, and convenient access to testing and treatment; and
 continued substance use, employment (lack of free time), contra-indications to
treatment, lack of reminders and lack of opportunity.
In conclusion, IDUs face multiple barriers to HCV care but a range of facilitators were
identified that could increase access to and uptake of treatment.
Hepatitis C management: the challenge of dropout associated with men and
injecting drug use
Lowry and colleagues (Lowry, et al. 2011). examined all referrals made to an urban tertiary
care liver centre for hepatitis C virus (HCV) management, tracked subsequent progress
and identified the dropout rate at the different stages. The authors completed a crosssectional retrospective review to examine HCV referrals received between 2000 and 2007.
The demographic, clinical and treatment data were extracted from medical charts and the
hospital information system.
A total of 588 individuals and 742 cases were referred for management of their hepatitis C.
Sixty-seven per cent of referrals were men and the average age was 33.3 years. Three
101
quarters (74%) of cases were injecting drug users; 83% were Irish; and 57% were referred
by their general practitioner. Other sources of referral were hospitals, drug treatment
centres, prisons and asylum centres. Of the 742 referrals, 141 (19%) failed to attend their
initial appointment, 180 (24%) dropped out from early outpatient management, 29 (4%)
failed to attend for liver biopsy and 81 (11%) did not attend subsequent outpatient followup. In total, 451 (61%) dropouts occurred. In those treated, a sustained viral response rate
(successful treatment rate) of 74% was observed. The number and proportion of patients
who experienced viral clearance varied with genotype: genotype 1, 18/30 (60%); genotype
2, 4/5 (80%); and genotype 3, 40/49 (82%). Those with a history of injecting drug use were
more likely than their non-injecting counterparts to drop out immediately after the referral,
drop out from early outpatient management and drop out over entire span of disease
management. Men were more likely (p<0.05) to drop out of disease management than
women. Eight individuals died during the study period.
The authors reported that an ‘exceptionally high rate of dropout exists’ among those
attending services to monitor and manage hepatitis C in injecting drug users, particularly in
the early stages of service delivery. The study findings have led to the development of
innovative approaches helping to optimise hepatitis C management in this population, such
as texting reminders and using a change model to improve engagement and compliance
with behaviour and treatment.
Hepatitis C virus in primary care: survey of nurses’ attitudes to caring
This study measured the knowledge of and attitudes towards hepatitis C among 560
nurses working in general practice, public health and addiction, and identified the
source of their knowledge (Frazer, et al. 2011). The researchers completed a crosssectional survey in 2006 with the nurses in the three categories of primary care through
a postal questionnaire in one region of Ireland. The questionnaire contained five
sections: demographic profile, work profile, knowledge, attitudes and education. The
questions were validated and pilot tested. The total number of primary care nurses
working in the region was 981, and 560 (57%) completed the questionnaire. The
response rates varied by type of nursing specialism: general practice, 57% (126);
public health, 55% (385); and addiction services, 83% (49). The attitudes of the nurses
towards hepatitis C were not presented in the paper.
Almost all (98%) of the nurses were female, and their average age was 43 years.
Nurses in the addiction services were younger than those in general practice or in
public health services. The nurses’ qualifications ranged from certificate (25%) to postgraduate degree (4%). Fifty-five per cent were qualified to diploma or higher diploma
level and 15% were qualified to at least degree level. Nurses in the addiction and in the
public health services had higher qualifications than those in general practice. Nurses
working in the public health service had longer service than those in addiction or
general practice. Addiction nurses were more likely to work full time.
Eighteen per cent had a personal friend or relative who had hepatitis C. Thirty-nine per
cent of respondents reported having professional contact with people with hepatitis C.
As expected, nurses in addiction services had more professional dealings with people
with hepatitis C (96%), compared to nurses in public health (30%) or in general practice
(44%). According to the authors, 90% of addiction service nurses provided information
on the dangers of alcohol, the benefits of hepatitis A and B vaccination, dietary intake
and transmission of the virus, while only 30% of nurses in public health provided advice
on the dangers of alcohol, and 11% of the same cohort on the benefits of hepatitis
vaccination. The advice provided by practice nurses was not reported.
Only 22% of nurses had received formal training on hepatitis C. Not surprisingly, a
higher proportion (86%) of nurses working in the addiction services received training on
hepatitis C, compared to the proportions working in public health (13%) or general
practice (16%). Ninety-six per cent of nurses working in the addiction services reported
that they were well informed about hepatitis C, while only 20% of practice nurses and
21% of public health nurses reported the same. The respondents were asked to
identify 21 statements about hepatitis C as true or false. Though the nurses working in
102
addiction services had good knowledge about hepatitis C, there were four statements
which 25% or more identified as true when they were false:
Hepatitis C can be spread through close personal contact such as kissing.
Hepatitis C is commonly spread through sexual transmission.
Most people who get hepatitis C will die prematurely because of the infection.
More than 50% of pregnant women with HCV will infect their children.
The level of knowledge among the public health and practice nurses was less than
desirable, with 25% of the nurses identifying at least 11 statements as true when they
were false. As well as the four listed above, these included:
People with hepatitis C should be restricted from working in the food industry.
Hepatitis C is a mutation of the hepatitis B virus.
There is no pharmaceutical treatment for hepatitis C.
HIV is easier to catch than hepatitis C.
Once you have hepatitis C, you cannot get it again because you are immune.
There is only one genotype of hepatitis C virus.
Hepatitis C is associated with an increased risk of liver cancer.
Twenty-five per cent of the nurses identified as false the following statement which is in
fact true: People can have the hepatitis C virus without being currently infected with the
virus.
The authors calculated mean knowledge-level scores for each group of nurses; the
mean score for addiction nurses was 22.5, for nurses working in public health 16 and
for practice nurses 16.9. The overall mean score was 16.7. Nurses were most likely to
have better knowledge about hepatitis C if they were younger, educated to degree level
or above, had attended a formal training course, personally knew someone with
hepatitis C, had professional contact with patients with hepatitis C, or considered that
they themselves were well-informed about hepatitis C.
Nurses working in public health services and general practice require formal training in
hepatitis C care and management. Nurses in the addiction services need to update
their knowledge in four areas.
7.4
Responses to other health correlates among drug users
7.4.1 Maternal and neonatal health among opiate users
Two recent papers present the results of studies on the health of women, who had
been prescribed methadone for the treatment of opiate dependence, and their infants
born in the Coombe Women and Infants University Hospital in Dublin. The first paper
reported that the services of a liaison midwife were required to encourage pregnant
women with opiate dependence to attend drug and maternity services regularly, and to
liaise between professionals in both services. The second paper reported that the
outcomes for mothers prescribed methadone and their new infants were not as good
as those for other mothers and infants attending the maternity service. See Chapter 12
below for an account of the key issues addressed in these two papers.
Bluebell Addiction Advisory Group (BAAG) was founded in 2004. The organisation
provides programmes such as the Get Active Group (GAP) for women and the Men’s
Gardening Group. GAP aims to fill the gaps left by addiction, such as boredom,
isolation and depression, through a programme of activities designed to tap into hidden
talents and build on existing interests.
GAP members took part in a six-week cookery course with chef Yves Tastet and
produced a cookbook focusing on nutrition and healthy eating in order to avoid health
problems such as depression, low energy levels and liver disease. The cookbook,
Filling a gap at BAAG, was launched by the Canal Communities Local Drugs Task
Force in 2010 (Bluebell Addiction Advisory Group 2010).
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Members of the group have visited other task force projects and recreated dishes from
the cookbook in an effort to motivate others to make nutrition and health a priority in
their recovery. A catering service run by GAP has catered for up to 100 people at
events organised by Dublin City Council, Canal Communities Local Drugs Task Force,
Rialto Youth Project and the Community Lynks Project.
GAP works in partnership with the Men's Gardening Group to create jobs within the
local community. The men’s group grows fruit and vegetables which are bought by
GAP for their catering business. The groups recently worked together to acquire skills
in producing Christmas wreaths and table centre pieces. The groups are currently
working together planting fruit trees and will produce jam for community sales in the
future.
The group has taken ownership of its activities; members carry out duties and roles,
including those of cookbook tour co-ordinator, leaflet and business card design and
donations manager. GAP provides summer camps and events for members’ children
so that the women can continue in their programme during school holiday periods.
New harm reduction booklet
On 6 May 2010 Use your head – harm reduction information – legal highs or otherwise
was published (Anna Liffey Drug Project 2011). This booklet provides harm reduction
information for individuals using psychoactive drugs – legal highs or otherwise. Issues
covered in the booklet include general harm reduction information, useful contact
telephone numbers, facts on overdose, the recovery position, rescue breathing and
chest compressions. The booklet has been developed in conjunction with Ana Liffey's
Peer Support Programme and other stakeholders.
The response to the booklet was positive with over 2,000 pre-publication orders placed
by a range of community, voluntary and statutory drug services across Ireland. The
booklet is the latest publication from the 'Duck, Dive & Survive' series, which is
recognised by the European Commission under the European Action on Drugs
Initiative. (Duck, Dive & Survive is an SMS service whereby Ana Liffey can offer realtime information to its clients on reducing the risks associated with drug use and
provide essential health and service-related information. (For more on Duck, Dive &
Survive, see Chapter 7.3 in Ireland’s National Report 2010 (Irish Focal Point 2010)).
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8.
Social Correlates and Social Reintegration
8.1
Introduction
The links between social exclusion and drug use in Ireland have been well established
(Keane 2007). Problem drug users in treatment tend to be young and male, have low
levels of education and are unlikely to be employed. For a small proportion, around
10%, homelessness and insecure accommodation are persistent problems. In recent
times there has been a modest increase in the proportion of other nationalities seeking
treatment (Reynolds, et al. 2008). Research also shows that there are problems with
illicit drug use among socially-excluded groups such as sex workers, homeless people
and new communities.
The aim of social reintegration is to empower individuals to plan and pursue alternative
activities to those they engaged in when using drugs. It achieves this through providing
accommodation, education, training and employment opportunities for recovering drug
users.
This chapter presents new data on the social correlates of drug use in Ireland, and
describes policy and programmes initiated in the past year to support the social
reintegration of recovering drug users. The broad policy approach and funding to
support social reintegration are briefly outlined in this section.
The National Drugs Strategy (interim) 2009–2016 (NDS) (Working Group on drugs
rehabilitation 2007) lists as a priority the implementation of the recommendations
contained in the report of the Working Group on Drugs Rehabilitation. It proposes that
the recommendations be incorporated in a comprehensive integrated national
treatment and rehabilitation service, using a four-tier model approach.
The Homeless Agency was formally replaced by The Dublin Region Homeless
Executive in July 2011. The executive is responsible for providing support and services
to the Dublin Joint Homelessness Consultative Forum and the Statutory Management
Group. The Housing (Miscellaneous Provisions) Act 2009 provides a statutory structure
to address the needs of people who are experiencing homelessness in Ireland. The Act
outlines a statutory obligation to have an action plan in place and the formation of a
Homelessness Consultative Forum and a Statutory Management Group.
The Community Employment (CE) scheme, funded by FÁS, the national training and
employment authority, includes 1,000 places ring-fenced for recovering drug users.
The scheme operates through local projects primarily in LDTF areas, where community
and voluntary groups are required to sign service agreements that outline the work
programme and the target outcomes for the individuals placed on the CE schemes.
The objective is to prepare participants for entry into the labour force, but the outcomes
outlined by most projects tend to refer to personal development, improved literacy skills
and education capital, and support progression to more specialised training and
education, rather than help the individual to find employment.
Acknowledging the CE scheme for helping recovering drug users to develop their
personal and employment skills and find a pathway back to work, the NDS suggests
that implementation of the Individual Learner Plan (ILP) would help to identify
participants’ needs and design progression routes towards labour market reintegration.
The development of targeted programmes by FÁS is seen as essential and should be
an integral part of the national drugs strategy in the future.
8.2
Social exclusion and drug use
Social exclusion and drug use remain intertwined and for some marginalised and
disadvantaged groups this association remains an intractable problem. Early school105
leaving and homelessness among drug users reporting for treatment shows little
change over the period 2005-2010 which suggests that measure to tackle these
problems are not having the desired effect. The situation of drug use among socially
excluded groups is discussed through examining six marginalised and disadvantaged
groups who report to be using various types and amounts of drugs. The research
reported, varies in quality and depth and we learn more about some groups than others
arising from these methodological variations. Nonetheless, this work provides a useful
lens through which to examine the intractable nexus of drug use and social exclusion.
Measures to tackle and remedy the association between social exclusion and drug use
are provided under the headings of accommodation, education and training and
employment.
8.2.1
Social exclusion among drug users
The National Drug Treatment Reporting System (NDTRS), which collects data on all
people attending drug treatment, is the most reliable database from which to capture
information on the socio-demographic profile of drug users in treatment. The database
includes information on type of accommodation and education that people report when
engaging in drug treatment. Within these categories there is room for people to report if
they are homeless or/and have left school early. These are two indicators of social
exclusion as they speak of marginalisation (homelessness) and disadvantage (early
school leaving). Table 8.2.1.1 provides data on both indicators among drug users
attending treatment between 2005 and 2010. Early school leaving among this cohort of
drug users has remained fairly steady at around 20%, which may suggest that
measures to tackle the association between early school-leaving and drug use are
having less than the desired impact. The number of cases reporting to be homeless
has not changed significantly which indicates that homelessness remains a problem for
a small proportion of drug users in treatment.
Table 8.2.1.1 Prevalence of social exclusion among all case reporting for drug treatment, 2005-2010
Social
2005
2006
2007
2008
2009
2010
exclusion
indicator
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
Homeless
217 (4.4)
303 (5.8)
300 (5.2)
382 (6.0)
315 (4.8)
463 (5.2)
Early school
986 (20.2)
1059 (20.2)
1149 (20.0)
1324 (20.9)
1315 (20.2)
1924 (21%)
leavers
Source: Unpublished data, NDTRS, 2011
8.2.2
Drug use among socially excluded groups
Drug use in disadvantaged communities
Saris and O’Reilly (Saris and O'Reilly 2010) undertook an ethnographic study of drug
use in a number of locations within the Canal Communities area in Dublin, These
locations are characterised by pockets of socio-economic disadvantage and have been
designated as areas experiencing high levels of illicit drug use. Data was collected
between September 2007 and the end of 2008, with some follow-up work in 2008. The
purpose of the study was to improve knowledge and understanding of the changing
nature of illicit drug use in the areas.
Data were collected using a variety of ethnographic methods, including informal and indepth interviews, focus groups, survey questionnaires and extensive field notes.
Interviews were conducted with 51 people, 24 life histories were collected and eight
group discussions with 29 young people. Return interviews were recorded with six
interviewees. Twenty-four interviews were completed with service providers. Survey
questionnaires were completed during face-to-face interviews with 92 people attending
drug treatment services. Data collection lasted approximately 12 months and it would
appear that the researchers spent extensive periods of time in the field throughout the
year. The researchers employed a number of tools to improve the quality of this work
including periods of reflexive practice and cross-checking data sources.
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Table 8.2.2.1 Lifetime and recent (past 3 months) illicit drug use among people recruited through
drug treatment centres in the Canal Communities, Dublin, data collected in 2008
Drug used
Lifetime use of illicit drug/s (n=92)
Heroin
Cocaine powder
Crack cocaine
Cannabis
Street tranquillisers
Street methadone
Number
92
73
55
82
65
47
%
100
81
61
91
72
52
Illicit drug use in the past 3 months
(n=92)
Number
%
58
63
20
22
28
30
55
60
42
46
16
17
Source: (Saris and O'Reilly 2010)
Table 8.2.2.1 paints a picture of poly-drug use among the participants in the study and
suggests that methadone is merely perceived to be another ‘street drug’ among many
that are used by the participants. According to Saris and O’Reilly, ‘...most users are
ambivalent about both [methadone] and the treatment regime. The majority of users
with whom we spoke, for example, do not consider methadone “treatment” as such.
Some talk about replacing “one addiction with another” or even more severely, being “a
government junkie”....’ (p. 19) Seventy-nine per cent of those using crack in the past
three months were also using heroin. Not reported in Table 8.2.2.1 is the use of licit
drugs among study participants. Ninety-eight per cent had used prescribed methadone
and 50% had taken prescribed tranquillisers in the last three months. Fifty-nine per
cent of those who had taken prescribed methadone in the last 3 months also reported
using heroin during this time.
Drug use among women involved in prostitution
Nelson (Nelson, et al. 2010) undertook a feasibility study in Tallaght, Dublin 24, to
assess the need for a service to meet the health needs of women working in
prostitution in the area. Tallaght is a large suburb in west Dublin with a population of
approximately 100,000. The area is characterised by socio-economic disadvantage:
high unemployment, low educational attainment levels, high levels of local authority
housing and is designated as an area with high levels of drug use. Thirty seven service
providers and nine women involved in prostitution were interviewed, 48 women
attending a women’s health project in Dublin’s city centre were surveyed and a focus
group with a number of service providers was organised. In addition to the nine women
interviewed who reported working in prostitution, service providers provided a profile of
97 other women who were known to be involved in prostitution and either living or
working in the Tallaght area. From this estimated number of 106 women working in
prostitution, it is claimed that 52 were known drug users, 45 were intravenous (IV)
heroin users, and 47 were in treatment with 42 receiving methadone; an estimated 13
of the IV heroin users were also known to use cocaine. The use of crack was small,
with only three women believed to be using. Thirty-three of the 106 women were
identified as foreign nationals and only one of these women was identified as an IV
heroin user.
Interviews with the nine women involved in prostitution revealed that financial
pressures and drug use were the key motivators for getting involved in prostitution; all
nine women had acquired educational qualifications including vocational training
certificates and one woman had a university degree. Information about the 97 women
profiled by service providers suggests that at least 35 were parents and the vast
majority were living with partners, family or friends or in private rented accommodation.
Seven of the women interviewed or profiled reported being homeless. The majority of
the women interviewed and profiled worked indoors either for themselves or for an
agency.
Drug use among the traveller population
The All Ireland Traveller Health Study (AITHS) (All Ireland Traveller Health Study Team
and School of Public Health Physiotherapy and Population Science University College
Dublin 2010) included 24 focus groups with members of the traveller community,
varying in size between five and 12 people. Twenty-seven semi-structured interviews
107
were conducted with members of the traveller community and service providers and
advocates working with the traveller community.
Addiction and alcohol and drug use were the main health-related concerns expressed
by travellers; drug abuse in particular was identified as a growing health threat among
male travellers. It was also reported that addiction and drug abuse remain unspoken
and hidden within the traveller community, with interviewees expressing shame and
denial as factors contributing to the concealment of drug abuse. Some interviewees
expressed the view that drug abuse was an act of cultural intrusion from mainstream
culture into traveller culture and that this was occurring against a background of cultural
shifts from traditional traveller lifestyles towards more mainstream cultural norms.
According to the authors of the report, ‘the issues experienced by Travellers in relation
to drugs are entwined with issues of inequality and marginalisation. This means that
Travellers are more likely to be exposed to the risk factors that lead to problem drug
use. It also implies that response mechanisms to address the associated problems
need to factor in these issues’. (p. 23)
Drug use among the homeless population
See Section 6.3.2 for a profile of this sample, including physical and mental health.
Drug use among early school leavers
In October 2008 the Joint Oireachtas Committee on Education and Science, assisted
by an expert group of researchers and practitioners, examined the problem of early
school-leaving in association with individual, home and school characteristics, including
structural features of the education system. Early school-leaving was defined as
leaving education without having completed the leaving certificate examination or an
equivalent. The leaving certificate is the final examination in the Irish secondary school
system.
The Oireachtas Committee, assisted by the expert group, reviewed the literature on
early school-leaving in Ireland, undertook secondary data analysis on the Programme
for International Student Assessment (PISA) dataset, undertook interviews and focus
groups with early school-leavers and some family members, and invited written
submissions from stakeholders in the area. The report of their work was recently
published and a summary of the main findings are provided below (Joint Committee on
Education and Skills (2010). Details of the 41 research participants and data collection
methods are listed below:
 Parents of early school leavers: 7 mothers and 2 daughters, focus group
 Young travellers: 6 males and 4 females, gendered focus groups
 Individuals recovering from heroin addiction: 4 male and 1 female, individual
interviews
 Young lesbians, gays, bisexuals and transgendered individuals (not all had left
school early but were deemed at high-risk due to bullying and absenteeism): 6
male and 3 female, focus group
 Young people with special educational needs: 1 male and 1 female, individual
interviews
 Young women who experienced rape or sexual assault: 2 women, interview by
phone
 Individuals in prison: 2 males and 2 female, individual interviews
The data were analysed using an inductive approach and constant comparative
method. A number of iterative themes were developed. Limitations of the study were
that convenience sampling was used and the number of participants was relatively
small.
Trauma and addiction is one theme developed in this research. According to the
authors, ‘almost all of the participants who had experienced addiction, heroin addiction
in particular, had also experienced some type of trauma, such as bereavement or
108
sexual abuse’ (p. 204). According to the accounts of the people interviewed, these
traumatic experiences were not helped by an indifferent response from their schools,
bullying and isolation by their peers, and an incapacity of the family unit to provide
adequate help and support. For these interviewees, using drugs became a means of
blocking out the experience and the pain and ‘fitting in’, albeit with what they now called
the ‘wrong crowd’.
Other issues arising from the data included:
 The transition from primary to post-primary school was a difficult and critical
period and some students needed more preparation and support.
 There was criticism of both curriculum and assessment in post-primary schools
with a preference for continuous assessment over the examination style
approach and also for interactive teaching methods rather than the didactic
approach.
 Teachers needed to be trained to identify, understand and respond to issues
such as bullying, for example when a student was being bullied because of their
sexual orientation.
Data from the Programme for International Student Assessment (PISA) dataset relating
to students’ early school-leaving intent (data collected in 2006) and reasons for early
school-leaving intent (data collected 2003) were analysed. (The data are derived from
a representative sample of the general school-going population of 15-year-olds.)
According to the report, student early school-leaving intent was strongly associated
with being a male student and having lower achievements in reading assessments.
Schools with an increasing number of disadvantaged students also experienced an
increasing rate of early school-leaving. Students in schools of similar socio-economic
composition who had higher levels of home-based educational resources and supports
were less likely to intend to leave school early compared to students with lower levels
of home-based resources and supports. Socio-economic disadvantage had a greater
negative impact on students in urban schools compared to students in rural schools.
8.3
Social reintegration
Social reintegration for drug users remains an aspiration of national drug policy
(Department of Community Rural and Gaeltacht Affairs 2009). Action 32 in the NDS
calls for the implementation of the recommendations of the report of the working group
on drugs rehabilitation (Working Group on drugs rehabilitation 2007). The
recommendations contain a number of actions to improve housing, education and
training and employment opportunities for people recovering from drug use. It is
proposed to undertake action on some of these measures within the context of the new
national drugs rehabilitation framework (NDRF) (Doyle and Ivanovic 2010). This
framework is currently being piloted in three sites. The new Programme for
Government includes a number of proposals to progress some of the
recommendations of the working group on drugs rehabilitation. (Fine Gael and the
Labour Party 2011)These include:
 expanding rehabilitation services at local level in line with need and subject to
available resources,
 assisting drug users in rehabilitation through participation in suitable local
community employment schemes, and
 developing compulsory as well as voluntary rehabilitation programmes
8.3.1
Housing
Applicability of the Housing First model to people with substance misuse issues
The St Dominic’s Housing Association (SDHA) recently commissioned research to
examine the applicability of the Housing First model to people with substance misuse
issues, and to identify best practice in relation to supports needed to ensure tenancy
sustainment for this vulnerable group (Brooke 2011). The defining feature of the
109
Housing First approach is its focus on assisting homeless people to move into
permanent accommodation and providing appropriate support services to sustain them
in their tenancy. In contrast to traditional approaches, the Housing First model does not
require people to be abstinent from substance use prior to securing accommodation.
The research project included a review of a selection of studies, and consultations
were undertaken with nine organisations and twelve service users in Ireland. In the
final report, the author concurred with the general consensus emerging from the
literature that stable accommodation is an important factor in encouraging people to
engage with treatment services and in achieving stability and abstinence. The report
highlights a number of issues, which are summarised below.
 A number of practical issues need to be considered when placing people with
substance addictions in permanent housing. These issues were raised during
consultations with stakeholders and were identified in a number of reports from the
UK which address this topic.
 A number of additional issues need to be considered before potential tenants move
into their new home, such as choice of location, the challenge of avoiding unwanted
guests, and sensitivity to perceptions of neighbours.
 There needs to be a clear understanding of the role of landlord and the visiting
support team and good lines of communication between the two. This approach
can ensure that any emerging issues around rent arrears or anti-social behaviour
can be dealt with in a timely and professional manner.
 According to the author, in Ireland the housing-related supports for Housing First
tenants could be provided by the Support to Live Independently (SLI) scheme
delivered by Dublin Simon Community.
 Loneliness and isolation were identified as major problems experienced by people
who misuse substances. According to the author, these people, who are mainly
young single men, may find themselves living in an unfamiliar area, perhaps living
alone for the first time, and at the same time cut off by choice from previous friends.
 Interviews with stakeholders revealed the importance of meaningful activity during
the day for service users who are housed. Participation in Community Employment
programmes and pursuing educational and recreational activities were mentioned
by service users as appropriate activities; the service users also talked about the
onset of boredom and potential relapse when their day lacked meaningful activity.
 The importance of family and social contacts were mentioned by stakeholders;
equally, it was said that, in some cases, family contact would not be a realistic
option in the medium or long term.
The report contains a number of extracts from interviews with individual substance
misusers. The general theme running through these accounts is that not all substance
users will benefit from the Housing First approach. Interviewees spoke about the
difficulties involved in managing the responsibility of paying bills and running a home
while actively using drugs. They recalled both personal and anecdotal experiences of
returning to the hostel or the street when the responsibility of maintaining their tenancy
became compromised by substance use. A number of interviewees spoke about the
problems of maintaining their tenancy while on crack cocaine. These accounts illustrate
the need for effective floating support when people who misuse substances are placed
in Housing First programmes. They require support with budgeting, cooking and other
domestic chores and encouragement to engage with treatment. Brooke concludes:
‘Although Housing First is largely untested in Ireland, and ... the specific case of people
with substance misuse problems is less well researched than other groups, there is
widespread belief among stakeholders in Ireland ... that provided it is done properly,
the Housing First approach can be successful for people with substance misuse
problems.’ (p. 20)
Piloting the Housing First approach in Ireland
The Dublin Housing First Demonstration Project, in line with the Homeless Agency
Partnership Vision to end the need to sleep rough on the streets, seeks to end the
need to sleep rough. The project has prioritised an identified number of entrenched
110
rough sleepers with significant support requirements including addiction. The project
has used the following criteria.
Each person will have:
 remained rough sleeping over a number of years,
 a broad range of significant support needs (this varies from person to person,
and may include physical, behavioural, personal care and hygiene, mental
health, drug use, alcohol use, etc ),
 refused a range of accommodation offers, and not engaged effectively with
available support services.
Current levels and methods of service provision have not proved effective in
responding to the support needs of these individuals.
The Dublin Housing First Demonstration Project will provide self-contained,
independent, scattered, community-based housing units for each participant, affording
them rights equal to any tenant renting privately. There will not be any staff employed
on-site. Support will be provided though home visits by the Housing First (HF) team,
which is an intensive case management team.
Initial housing units have been provided by Stepping Stone Ltd. A number of housing
units will be available every three months, and 20 units in total will be available during
the first 12 months of this demonstration project. This will allow a rolling entry into the
project and phased increase in the caseload of the team.
The project is client-led: participants choose to take part in the project, choose their
housing unit as far as possible, identify their own goals, and the HF team works with
the person to achieve their goals. In this way, the project aims to promote participants’
autonomy, independence, and to support them in settling into their home and
integrating into their community. Participants will be invited to participate in Housing
First, and when they choose to do so, they will choose from a number of housing units.
They will be supported to:
 prepare for the move-in,
 actually move-in and have furniture, soft furnishings and groceries provided
for the move-in,
 access relevant benefits and entitlements,
 review their support needs, and establish goals,
 access the services of the HF team,
 access relevant services not represented on the HF team directly, and
 maintain their housing and integrate into their community.
A three-year longitudinal evaluation of the project is being conducted by Dr Ronni
Greenwood, UL/ Pathways New York. This evaluation will produce an initial report
reviewing the first 12 months of the project. It is envisaged that this report and the
overarching evaluation will make recommendations regarding the potential application
of this model in the Dublin region and nationally. Participants will continue to be
supported, even if they cannot sustain the tenancy (personal communication, Elaine
Butler, Homeless Agency, 2011).
Accommodation services for homeless drug users
Focus Ireland is an independent charity that works to improve the lives of homeless
people through a programme of prevention, support, housing, advocacy, research and
communication. Their latest annual report describes the services they provide for
homeless drug users and gives some indication of the numbers that benefit from using
these services (Focus Ireland 2011). These services are noted below.
The Step-Down Programme is a residential facility for people who have completed a
drug rehabilitation programme and require support in learning to manage a home of
their own. Focus Ireland works in partnership with Keltoi Residential Therapeutic
Facility, the HSE’s Rehabilitation Integration Service (RIS), Coolmine Therapeutic
111
Community, and Aislinn in delivering the service. In 2010, the service worked with 20
customers, supporting nine in accessing private rented accommodation and one in
accessing local authority housing.
The Caretakers Hostel and Case Management Service is a partnership project
between Focus Ireland and the Society of St Vincent de Paul. The project works with
hard-to-reach young people aged between 16 and 21 who are sleeping rough and
actively using drugs. The service provides a safe place to sleep, hot meals and basic
facilities such as shower and washing. The project also provides a case management
and liaison service with one-to-one support for young people, to help them access drug
treatment services and education and/or training and alternative accommodation by
advocating on their behalf. In 2010, the service worked with 46 young people.
Aylward Green Supported Temporary Accommodation for Families is now the only
service of its kind in Dublin, providing emergency accommodation for families who are
homeless and have complex needs. In addition to providing temporary
accommodation, the service provides intensive support in response to a variety of
needs, including drug and alcohol addiction, relationship difficulties, anger
management, and mental and physical health issues. In 2010, the service provided
accommodation for 24 families.
8.3.2
Education, training
Education and training are provided to people in recovery from drug addiction through
a number of projects. Some projects (exact number unknown) use the FÁS model to
provide this service. The FÁS model works through the Community Employment
Scheme, which has dedicated at least 1,000 places to drug users in recovery so that
they can return to education and training. The activities undertaken by people in
recovery when they engage with projects include personal development, relapse
prevention, literacy and numeracy skills and varied types of vocational training such as
computer skills. There has been no recent evaluation of this programme and reporting
on its activities is not an exercise undertaken on a regular basis. However, recent
estimates suggest that around 850 of the 1,000 dedicated places for people in recovery
are actually taken up and used with the majority of places being used by females in
recovery (Eamon Carey, personal communication, FÁS, 2011).
In contrast to the FÁS model, a number of other programmes working with people in
recovery adopt a more individualised type of approach. For example, Soilse uses an
adult education model, based on the experiential learning approach promoted by Paulo
Freire. This approach situates the learning experience of the individual in their real-life
experience both past and present and encourages deep reflection on the issues that
contributed to their addiction and which in many cases constrained their life-chances.
The approach is broad and flexible and encourages the uptake of new interests and
skills, components that are seen as central to maintaining recovery.
The success of this programme was publicly acknowledged in October 2010, when 96
Soilse participants celebrated their achievements in adult education when receiving
Further Education and Training Awards Council (FETAC) qualifications. From the
perspective of Soilse, FETAC qualifications are an important step in progressing to
further education and training. Six participants also received certificates for completing
the Soilse–NUI Maynooth Return to Learning (RTL) course, which has been designed
and implemented by Soilse. The RTL course was designed to meet the needs of
participants who were in full-time education and who were having difficulty dealing with
the demands of academic life and college culture. Soilse places great importance on
the value of adult education as a vehicle of personal empowerment and social
reintegration. It has developed strong links with adult education providers in Dublin and
many of its past and current participants have gone on to study at University College
Dublin (UCD), Trinity College and National University of Ireland (NUI) Maynooth.
112
Research due to be published in the last quarter of 2011 will demonstrate how
education can contribute to the development of recovery capital (Keane and
McAleenan In press) Recovery capital is a concept developed by (Cloud and Granfield
2009) and refers to the sum of social, physical, human and cultural capital that is
necessary to initiate and sustain recovery from addiction. The research, based on indepth interviews with 20 people from the Soilse programme who were in recovery from
opiate addiction and who had returned to third-level education, will show that education
can play a role in developing the four dimensions of recovery capital by improving:
 social capital by opening up opportunities to develop new networks of friends,
 physical capital by increasing job opportunities which can improve living standards
and conditions,
 cultural capital by exposing people to new values, beliefs and attitudes, and
 human capital by empowering people to look after their health, develop achievable
goals and helping with the day-to-day problem solving that is part of the process of
addiction recovery.
8.3.3
Employment
Ready for Work (RFW) is a supported employment programme which aims to help
people affected by homelessness to move towards independent living by gaining and
sustaining employment. The programme has been operating in Ireland since 2002 and
since its inception has worked with over 300 people affected by homelessness and 57
corporate businesses who have provided work placements for clients of the
programme.
The programme provides pre-employment training to clients to build confidence and
communication skills, manage change, prepare their curriculum vitae and undertake
mock interviews. In a recent evaluation of the programme, the vast majority of
candidates rated the training very highly. (Business in the Community Ireland 2011)
The programme also works with participants to match their skills and interests to the
work placements being offered by participating businesses. The work placement has
four components to support the participant:
 A volunteer from the business acts as a ‘buddy’ to the participant during their
placement to help them fit in and gain maximum benefit from their experience. The
RFW team also provides support during the placement.
 The participant can work part-time to allow for childcare responsibilities, medical
appointments etc and to build a routine gradually.
 The participant can choose to work only Monday–Friday, when the RFW team is
available to provide support if needed.
 The participant can choose to work unwaged to prevent interruption to social
welfare payments.
Table 8.3.3.1 Number of participants, and range of RFW activities, 2002–2011
Programme activity
Number of participants
Started pre-employment training
315
Completed pre-employment training
293
Started work placement
286
Completed work placement
233
Started employment
124
Started further training and education
63
Started volunteering
10
Source: (Business in the Community Ireland 2011)
The programme is run four times per year and feedback from participants that took part
in the recent episode of the programme suggests that the work placement is an
enriching and rewarding experience. Participants reported an improvement in selfconfidence and commitment to employment; they felt welcomed by other employees;
they were supported by their ‘buddy’ and they gained new skills. Some reported
difficulty getting back into a routine (Business in the Community Ireland 2011) Table
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8.3.3.2 provides a profile of activities and numbers engaging during the recent episode
of the programme.
Table 8.3.3.2 Number of participants engaged in RFW activities during last quarter of 2010
Programme activity
Number of participants
Started pre-employment training
15
Completed pre-employment training
14
Started work placement
15
Completed work placement
11
Source: (Business in the Community Ireland 2011)
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9.
Drug-related crime, prevention of drug-related crime and
prison
9.1
Introduction
This chapter presents the most recent statistical data on drug-related crime in Ireland.
It also describes policies and programmes initiated in the past year to prevent drugrelated crime both in the community and in prisons as well as research studies on drugrelated crime, prevention and prison. In this section the data sources and types of drugrelated crimes in Ireland are described, and the approaches to preventing drug-related
crime, both in the community and in prisons, are also briefly outlined.
Since 2006 reporting crime statistics has been the responsibility of the Central
Statistics Office (CSO). The CSO data are derived from the Garda Síochána
computerised PULSE system (Police Using Leading Systems Effectively).
The vast majority of drug offences reported come under one of three sections in the
Misuse of Drugs Act (MDA) 1977: section 3 – possession of any controlled drug
without due authorisation (simple possession); section 15 – possession of a controlled
drug for the purpose of unlawful sale or supply (possession for sale or supply); and
section 21 – obstructing the lawful exercise of a power conferred by the Act
(obstruction). Other MDA offences regularly recorded relate to the importation of drugs
(section 5), cultivation of cannabis plants (section 17) and the use of forged
prescriptions (section 18).
Driving under the influence of drugs (DUID) has been a statutory offence in Ireland
since the introduction of the 1961 Road Traffic Act. The principal legislation in this area
is contained in the Road Traffic Acts 1961 to 2002. Section 10 of the Road Traffic Act
1994 prohibits driving in a public place while a person is under the influence of an
intoxicant to such an extent as to be incapable of having proper control of the vehicle.
Intoxicants are defined as alcohol or drugs and any combination of drugs or of drugs
and alcohol. Although penalties for driving under the influence of alcohol are graded
according to the concentration of alcohol detected, the law does not set prohibited
concentrations for drugs. Neither does it distinguish between legal and illegal drugs.
Tests to identify the level of impairment can only take place where there is a
reasonable suspicion that an offence is being committed.
In reading the tables in this chapter, please note that ‘relevant proceedings’ refer to
the legal proceedings, such as prosecution, taken in relation to an offence as it was
originally recorded in the PULSE system. ‘Proceedings’ is a list of charges and
proceedings which do not necessarily relate to an offence as originally recorded in the
PULSE system.
Over and above the ‘inherent’ drug crimes, that is crimes under the Misuse of Drugs
Acts or the Road Traffic Acts, ‘non-inherent’ drug crimes are also recorded in Ireland,
for example acquisitive crime to pay for drugs, crimes of intimidation and violence
inflicted by drug gangs, money laundering, smuggling or other finance-related crimes,
or public nuisance. However, they are not reported in this chapter as it is not possible
to separate those associated with the operation of the illicit drug market from those not
associated with illicit drugs.
Crime prevention in Ireland proceeds on several fronts. Tackling community
disadvantage is one important approach. Disadvantage in communities is recognised
as a risk factor in contributing to, among other things, the spread of drug-related crime.
A wide range of national initiatives exist to tackle disadvantage and its consequences,
including community and local development programmes, the RAPID and CLAR
programmes, and targeted urban regeneration projects. These initiatives all contain
components relating specifically to illicit drugs. Specifically in relation to the drug
problem, in 1998 local drugs task forces (LDTFs) were established in areas identified
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as having the highest concentrations of drug misuse; without exception, these areas
were all also experiencing high levels of disadvantage. The purpose of the LDTFs is to
co-ordinate local action plans in relation to curbing local supply as well as treatment,
rehabilitation, education and prevention. A central feature of the LDTFs is that as well
as co-ordinating the provision of services locally, they also allow local communities and
voluntary organisations to participate in the planning, design and delivery of services.
Diversion is another important means of seeking to prevent crime including drugrelated crime – both before, and after, a crime has been committed. Garda Youth
Diversion Projects are local community activities which work with children. These
projects aim to help children move away from behaving in a way that might get them or
their friends into trouble with the law. In 2005 the Irish Youth Justice Service (IYJS)
was established to develop a co-ordinated partnership approach among agencies
working in the youth justice system, to improve service delivery in the system through
diversion, restorative justice, rehabilitation and detention as a last resort. Garda (Irish
police force) statistics show that the types of offence committed by children under the
age of 18 years are primarily theft, alcohol-related offences, criminal damage, assault,
traffic offences, drugs possession, public order offences and burglary. The Garda
Juvenile Diversion Programme is used to deal with children under 18 years of age who
have committed offences, including alcohol-related and drug possession offences. This
programme exists across the country and is included as part of the Children Act 2001.
First established on a pilot basis in 2001 the Drug Treatment Court is a specialised
District Court which offers long-term court-monitored treatment, including career and
education support, to offenders with drug addictions as an alternative to a prison
sentence. The idea is that by dealing with the addiction, the need to offend is no longer
present.
Finally, individuals and communities are encouraged to participate in helping to prevent
and/or detect crime. For example, the Customs Drugs Watch Programme, first
launched in 1994, encourages those living in coastal communities, maritime personnel
and people living near airfields to report unusual occurrences to Customs. Under the
Garda Síochána Act 2005, Joint Policing Committees (JPCs) have been established in
local authority areas to bring together public representatives, representatives of local
authorities, the Garda Síochána and representatives of the voluntary and community
sectors to assess levels of crime and anti-social behaviour, including that related to
alcohol use and illicit drug use, and to make recommendations as to how to prevent
and address such problems. The JPCs are empowered to establish local policing fora
(LPF), to deal specifically with drugs and associated issues such as estate
management and anti-social behaviour. In September 2008 a Dial-to-Stop Dealing
campaign was launched and operates nationwide; individuals and communities
affected by drug dealing are urged to pass information by dialling a confidential
number.
The presence of drugs in prisons led the Irish Prison Service (IPS) to develop a policy
based on three underlying principles (Irish Prison Service 2006b):
 the presence of drugs in prison will not be tolerated;
 prisoners will be encouraged and supported to develop a responsible attitude to
drugs, both while in prison and following release, through a range of measures
including education and counselling; and
 prisoners who are addicted to drugs or have other medical problems caused by the
misuse of drugs will be offered every reasonable care and assistance.
In the accompanying strategy the IPS lists two aims in relation to illicit drugs in prisons:
(1) to eliminate the supply of drugs into prisons, and (2) to provide prisoners with a
range of opportunities which encourage them to adopt a drug-free lifestyle, before and
after release, thereby reducing demand for drugs.
The Probation Service works in partnership with communities, local services and
voluntary organisations to reduce offending and to make communities safer. It funds
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and supports organisations and projects providing drug treatment to offenders, as well
as other important services such as employment placement, accommodation,
education and training, restorative justice initiatives. Probation Service staff in the
community and in prisons may refer clients to these community-based projects, to
enhance their re-integration and resettlement as positive, contributing members of their
communities.
9.2
Drug-related crime
9.2.1
Drug law offenses
Figures 9.2.1.1 and 9.2.2.2 show trends in proceedings for drug offences from 2004 to
2009 (See Standard Table 11). As can be seen from Figure 9.2.1.1, criminal
proceedings for the possession of drugs for personal use (simple possession)
decreased in 2009 for the first time since 2004. Possession offences accounted for
74.5 % of total drug offences (n = 13,547) in 2009. Proceedings for drug supply also
decreased marginally, from 2,964 in 2008 to 2,721 in 2009, returning to the same level
as 2007.
16000
14000
Number
12000
10000
8000
6000
4000
2000
0
2004
2005
2006
2007
2008
2009
Total drug offences
5799
8291
8952
11713
14349
13547
Drug possession for
3762
5861
6103
8346
10746
10093
personal use
Drug possession for
1654
1987
2323
2725
2964
2721
supply
Figure 9.2.1.1 Trends in relevant legal proceedings for total drug offences, drug possession for
personal use and for supply, 2004–2009
Source: CSO (Central Statistics Office 2009) (Central Statistics Office 2011)
Figure 9.2.2.2 shows trends in legal proceedings for a selection of other drug offences
between 2004 and 2009.
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450
400
350
Number
300
250
200
150
100
50
0
Obstruction
Forged/altered
prescriptions
Cultivation or
manufacture
Importation/manufacture
2004
239
2005
290
2006
349
2007
406
2008
328
2009
390
85
95
91
91
119
139
32
29
54
110
136
163
27
29
32
35
56
41
Figure 9.2.1.2 Trends in relevant legal proceedings for selected drug offences, 2004–2009
Source: CSO (Central Statistics Office 2009) (Central Statistics Office 2011)
The offence of obstructing the lawful exercise of a power conferred by the Misuse of
Drugs Act, 1977 (s21) continues to be the largest category. Following a decline in
2008, proceedings for such offences increased in 2009, as did cultivation offences and
forged prescription offences. Importation offences decreased marginally in 2009.
Obstruction offences often involve an alleged offender resisting a drug search or an
arrest or attempting to dispose of drugs to evade detection. Proceedings for the
cultivation or manufacture of drugs have continued to increase since 2005. In 2005
there were 29 proceedings for such offences. In 2009, the number of proceedings for
drug cultivation/manufacture had risen to 163 offences. It is unclear whether this
increase reflects a genuine growth in the commission of such offences or whether it
reflects a sustained concentration of law enforcement on detecting such offences.
Courts Service Annual Report 2010
The Courts Service Annual Report for 2010 provides statistics on the outcomes of
prosecutions for drug offences between January and December 2010 (Courts Service
2011). Table 9.2.1.1 shows the outcomes of trials for 16,939 drug offence cases
prosecuted in the District Court, the lowest court in the system where most drug
offences are dealt with. The most common outcome was for cases to be struck out
(22.6%, n=3,834), followed by fines (19.2%, n=3,249). Almost 10% (1,588) of cases
resulted in a prison sentence.
Table 9.2.1.1 Sentences for drug offences in the District Court, 2010
Sentences Imprisonment Fines Community Struck Dismiss
service/
out
probation
Number of
1588
3249
2107
3834
310
offences
Taken into
consideration*
Other
Peace
bond
Total
2460
2997
394
16939
* Taken into consideration: The Criminal Justice Act, 1951, s8, provides that where a person, on being convicted of an offence, admits
him - or herself guilty of any other offence and asks to have it taken into consideration in awarding punishment, the Court may take it into
consideration accordingly. If the Court takes an offence into consideration, a note of that fact is made and filed with the record of the
sentence, and the accused cannot be prosecuted for that offence, unless her/ his conviction is reversed on appeal.
The Courts Service reports that 1,186 drug offences were tried in the Circuit Court,
which has a higher jurisdiction than the District Court and can thus impose a more
severe sentence. Of these prosecutions, 767 led to guilty pleas. Of the 46 cases which
went to trial, 14 resulted in convictions, 14 in acquittals and 18 in a nolle prosequi,
where the prosecution enters a stay on criminal proceedings. The data provided does
specify the precise sentence imposed in relation to the 14 convictions.
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Drug driving offences
800
700
Number
600
500
400
300
200
100
0
Number of
prosecutions
2005
2006
2007
2008
2009
70
73
205
567
695
Figure 9.2.1.3 Trend in relevant legal proceedings for driving in charge of a vehicle while under the
influence of drugs, 2005–2009
Source: (Central Statistics Office 2011)
Figure 9.2.1.3 shows the trend in prosecutions for driving under the influence of drugs
(DUID) between 2005 and 2009. Between 2005 and 2009 the number of prosecutions
for DUID increased from 70 to 695, an increase of more than 900%. It is unclear why
this increase has occurred. It could either be due to an increase in the incidence of
DUID or the more likely possibility that there has been an increase in targeted police
activity in this area.
9.2.2
Other drug-related crime
Drug-related violence and intimidation
CityWide Drugs Crisis Campaign hosted a conference in May 2011 addressing the
issue of drug-related crime and intimidation. Over 80 people attended the half-day
event in Dublin’s north inner city. The conference followed an event in October 2010 at
which CityWide hosted a meeting titled: ‘A community drug problem: defining the
problem – defending the responses’, where the issue of intimidation emerged as a
central issue for many communities throughout Dublin (Connolly 2011).
In 2009 the Family Support Network (FSN), which was established in 2000 to support
the development of family drug support groups throughout Ireland, published the
findings of research into the issue of intimidation of the families of drug users by those
involved in drug dealing (O'Leary 2009). Through its work, the FSN became aware of a
large number of families experiencing intimidation as a result of a family member’s
drug-related debts. The intimidation of drug users and their families has also been
highlighted as a key issue in the National Drugs Strategy 2009–2016 (NDS)
(Department of Community Rural and Gaeltacht Affairs 2009). Action 5 of the NDS
aims ‘To develop a framework to provide an appropriate response to the issue of drug
related intimidation in the community.’
The CityWide conference began with four short presentations. Detective
Superintendent Michael O’Sullivan of the Garda National Drugs Unit reported on a pilot
project in the Dublin Metropolitan Region. Established in March 2011 for a six-month
trial period, the pilot works closely with the Family Support Network, and is designed to
provide families and the wider community with a point of contact with the Garda
Síochána. The project is to be reviewed at the end of August and, following feedback
from stakeholders, is to be rolled out nationally. Graham Ryall, a community activist in
the Canal Communities in Dublin’s south inner city, set the current issues against the
historical backdrop of the 1980s and 1990s when anti-drugs groups such as the
Concerned Parents Against Drugs (CPAD) emerged throughout the city to tackle drug
119
dealing. In recent years, a partnership approach in Dolphin Housing complex in the
south inner city involving the gardaí and local residents managed to put an end
temporarily to open drug dealing. However, the economic downturn and the ‘shelving of
plans’ to regenerate Dolphin House has, according to Ryall, ‘had a major negative
impact on the community’.
The third speaker, Audra Cotter of the Clonmel Community Based Drugs Initiative in
Tipperary, reported on an inter-agency initiative which has been positively evaluated
and which is currently being rolled out across the south east region. Prior to this
initiative, families who needed advice or direction from the gardaí were reluctant to
attend the local Garda station for a number of reasons, including the lack of
consistency in the Garda personnel they would encounter. Now, families can meet
specific gardaí from the Community Policing Unit in venues in which they feel safe and
comfortable. Johnny Connolly of the HRB highlighted the limited knowledge base in
this area and the general failure of research and other information sources historically
to properly reflect the local impact of drug-related crime and intimidation on the
individuals, families and communities most affected. He cited a recent Limerick study to
illustrate the way in which gangs can employ a variety of strategies, from serious
violence to verbal abuse and vandalism by young children, to instil fear and impose
territorial control on communities (Hourigan 2011). In terms of building sustainable
responses, the potential of community-based mediation and the further enhancement
of JPCs were highlighted.
The final part of the conference was dedicated to workshops where participants
addressed the following three questions:
 What is the level of intimidation in your community?
 How has your community responded to the issue of intimidation so far?
 What actions need to be taken?
The level and types of intimidation reported ranged from graffiti and low-level
harassment directed at vulnerable people to the killing of family pets, beatings,
stabbings, hostage taking, the petrol bombing of people’s homes, threats of and actual
sexual violence, shootings and murder. Threats of violence come from money lenders
as well as from drug dealers. Gang members were known to wait outside post offices
and dole offices to collect money from dependent drug users. Individuals also reported
being forced to smuggle drugs into prison as part payment of a drug debt. Although
many people turned to credit unions to pay drug debts, it was reported that many credit
unions are now refusing to provide loans in such circumstances.
Single mothers living alone were particularly vulnerable; having to store or smuggle
drugs as payment for a child’s drug debt contributed to high stress levels, leading to
illness and depression. In such circumstances, the growing dependency of such people
on prescription drugs exposes an ironic connection between illicit and licit drug
markets. A rise in suicides by those in debt was also reported, although the debt does
not die with the person. Another ominous development was the disruption of local drug
projects, either through graffiti or with gang members loitering outside projects to
intimidate drug workers and clients. Outreach and healthcare workers reported being
unable to enter certain areas because of control exerted by individuals or gangs.
With regard to community responses, all areas as represented by those in attendance
at the conference reported a reluctance to report incidents to the gardaí owing to fear
of reprisals. One immediate consequence of this is that the true levels of intimidation
are not officially recorded anywhere. Where people did make formal complaints, it was
felt that a promise of full Garda protection was not forthcoming. Community policing
fora, where they existed, did help to build trust between the Garda Síochána and the
local community. Also, an increase in Garda presence on the ground was reported as
having a positive effect, although it could not be sustained over the long term. Similarly,
CCTV had limited or no impact, as footage captured on cameras was reportedly not
120
regularly monitored. Where it was monitored, the intimidatory activity appeared simply
to be moved elsewhere.
A recurring theme related to drug-related intimidation within the Traveller community.
The close-knit and isolated nature of the community meant that issues were seldom if
ever reported to the gardaí. Where Travellers did report to the gardaí, other minor
issues such as road tax were sometimes raised with the complainant, leaving them
reluctant to engage further with the gardaí.
Services also face difficulties working with young people who are themselves involved
in intimidating others, as some will arrive in to services in bullet-proof vests and
carrying guns. On the other hand, a great deal of positive youth work was reported at
the conference, including efforts to encourage problematic youth into facilities and
exploring perceptions of crime among young people. Another initiative involved young
people working with senior citizens, teaching them how to use computers, for example.
A local area partnership initiative involved attempts to promote a positive sense of
community in response to anti-social behaviour. Despite these positive examples, in
general, most delegates at the conference reported a sense of frustration at the
absence of effective responses to the serious issues being confronted.
With regard to possible future approaches, a range of ideas were discussed, including:
 More secure ways of reporting problems and more protection for those reporting.
 A ‘Dial to Stop Intimidation’ service, to be promoted as a community-based
campaign, taking the emphasis away from Garda involvement so as not to deter
people from making calls. Community workers could also assist service users to
make reports using this mechanism.
 An evidence base of incidences of intimidation, initially to be compiled informally at
local level.
 More resources into early interventions and youth development work.
 JPCs be made more effective and accountable.
 The court system to fast track intimidation charges and to ensure that evidence can
be given safely.
 Community-based mediation, and community representatives to mediate safety
issues with drug dealers.
 A national conference/national day on intimidation to highlight the issue and create
unity among communities.
It was agreed that the Citywide Drugs Crisis Campaign would facilitate the
establishment of an Intimidation Working Group comprising specialists from various
agencies and representatives from the community and voluntary sector (Citywide
2011).
Drug markets study - the impact of drug dealing and drug markets on local
communities
The first comprehensive study of Irish illicit drug markets is due to be published in late
2011 (Connolly and Donovan In press). See Chapter 10 for a full account of this study.
The following findings relate to the impact of drug dealing and drug markets on local
communities.
The study incorporated a street survey of approximately 800 residents in the four
locations where the study took place. The majority of respondents surveyed in all four
sites considered illegal drugs to be a big problem in their area, ranging from 67% of
respondents in site C to 90% of respondents in site A. However, residents’ direct
exposure to drug problems, whether through witnessing drug-using behaviour or
seeing discarded syringes in their neighbourhoods, differed across the four sites. In
site A, of the 60% of respondents who had directly observed drug use in their area,
89% had observed people smoking drugs and almost 50% had seen discarded
121
syringes in their neighbourhood. In site B, 31% of respondents had directly observed
drug use, 75% had seen people smoking drugs and 22% had seen discarded needles
in the 12 months prior to the study. In site C, again, 31% of respondents had directly
observed drug use. Of these, 90% had seen people smoking, but just 9% had seen
discarded needles. In site D, which, like site A, had a deeply embedded and thriving
open drug market, 55% of respondents had directly observed drug use, almost 90%
had witnessed people smoking drugs, and 50% had seen discarded needles in their
neighbourhoods.
Open drug markets impacted on local communities by curtailing residents’ freedom of
movement. In site A, almost two thirds of respondents avoided certain areas at certain
times, primarily because of people hanging around in groups taking drugs. Sixteen per
cent cited open drug dealing as a concern. Over half of respondents in site B avoided
certain areas at certain times, mostly because of people taking drugs and consuming
alcohol. In site C, 40% of respondents avoided certain areas at certain times, owing
primarily to people hanging around in groups. Of the 41 respondents who gave reasons
for their avoidance of certain areas, 10 specifically cited the incidence of people
hanging around taking drugs. In site D almost half of respondents avoided certain
areas at certain times, with 44% of those doing so because of people hanging around
taking drugs. This loss of communal space can contribute to a further deterioration in
community quality of life. Irish and international research has shown that the
detachment of ordinary residents from the place in which they spend their daily lives
can create a sense of disempowerment, which further undermines attempts to address
this decline in the quality of life in a community. The literature also shows that this cycle
of alienation and decline can operate as a catalyst for progressive criminal behaviour,
thereby intensifying the grip of local drug markets.
9.3
Prevention of drug-related crime
9.3.1
Drugs and driving
The new programme for government, Government for National Recovery 2011–2016
(Fine Gael and the Labour Party 2011) contains a number of actions related to criminal
justice and drugs policy, including the following:
We will introduce roadside drug testing programmes to combat the problem of driving
under the influence of drugs.
The development of reliable roadside testing procedure has been a challenging issue
for many countries. At present the Garda Síochána, the Department of Transport and
the Medical Bureau of Road Safety are collaborating in the development of a scheme
to introduce US-style roadside tests on suspected drug drivers to accompany roadside
alcohol tests.
9.4
Interventions in the criminal justice system
Dial-to-stop drug dealing
In response to a Parliamentary Question, the Minister of State at the Department of
Health with responsibility for Primary Care, , Roisín Shortall TD, stated with regard to
the dial-to-stop drug dealing campaign (see Ireland National Report 2010 (Irish Focal
Point 2010), section 9.4.2, for an overview of this campaign):
The campaign was re-launched in October 2010 with a two week national
promotional campaign, followed by local campaigns at Drugs Task Force level.
Since 2008, over €689,000 has been allocated to this campaign. The phone line
has resulted in over 9,800 calls received and 2,800 reports made to the Gardaí.
An evaluation of the 2010 campaign has been completed and is currently under
consideration. The evaluation will inform the future approach to the initiative
(Shortall 2011, 31 May-b).
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9.4.1
Alternatives to prison
Drug Treatment Court (DTC) expanding
In May 2010 the Minister for Justice, Equality and Law Reform, Dermot Ahern TD,
published a review by his department of the DTC, which had been operating in Dublin
since 2001 (Department of Justice Equality and Law Reform 2010c).
Highlighting the low number of participants entering and successfully completing the
DTC programme, the review made several recommendations designed to improve the
court’s operational effectiveness and overall success rate (Connolly 2010). It was
decided that, having implemented the recommendations, the DTC should continue its
operations for a further two years.
Although the review found that only 14% of programme participants had graduated
from the programme since its establishment, participation in the programme was seen
to have had a positive effect on behaviour. Although many participants took several
years to progress through the initial phases of the programme, the focused attention
and support they received during this period had ‘a positive effect on their offending
behaviour, as well as on their health and personal relationships’, even if they ultimately
failed to complete the programme. Writing in the March 2011 issue of Courts Service
News, Tom Ward, chief clerk of the Dublin Metropolitan District Court, reports on how
the programme has been adapted to address this issue:
The principal achievement over the past year has been the agreement of a new
strength’s (sic) based approach to determining the progress of participants… .
Under the new system, participants continue to be tested as part of their
treatment with progress measured over the period of participation. A greater
weighting is ascribed to positive behaviours, such as not coming to
unfavourable notice of the Gardaí. Participants receive credits for attending the
in-house support group which is based on the ‘12 steps’ approach to managing
addictions. Interim achievements are recognised and those who achieve a
silver standard, but do not manage to attain gold, may be the subject of a report
from the Drug Treatment Court Judge to their Sentencing Judge, proposing a
suspended rather than a custodial sentence.((Ward 2011): p. 5)
Ward also reports on the establishment of a Support and Advisory Committee to assist
the DTC. This committee comprises senior managers from the HSE, the Garda
Síochána, the Probation Service, City of Dublin Vocational Education Committee
(VEC), the Health Research Board and the Courts Service. According to Ward, ‘The
Court hopes to be able to accept participants with addresses outside the Dublin North
Inner City in the near future. In the meantime, it continues to encourage referrals from
those with addresses in Dublin 1, 3 or 7’ (p. 5).
The review of the DTC recommended that the programme be extended to offenders
aged 16–18 years who are before the Children Court. The new Programme for
Government is also committed to carrying out ‘a full review of the Drug Treatment
Court programme to evaluate its success and potential in dealing with young offenders
identified as having serious problems with drugs’ (Fine Gael and the Labour Party
2011). An interim assessment of the DTC is due to take place in the autumn (Tom
Ward, chief clerk of the Dublin Metropolitan District Court, personal communication,
June 2011). This will examine the progress made to date in implementing the
recommendations made in the review.
Responding to a Parliamentary Question on the DTC, the Minister for Justice and
Equality, Alan Shatter TD, stated:
As a result of that review an Advisory Committee was established which has
met regularly to progress matters and to monitor the implementation of the
recommendations in the Report with the aim of improving the programme’s
throughput and effectiveness…The aim is to develop the potential of the Drug
Treatment Court but to do so in line with the international experience by
123
continually reviewing the effectiveness of the programme to ensure that it is
meeting its objectives and, if it is doing so, to continue to expand the use of the
Drug Treatment Court as an alternative to prison. A further review of the Drug
Treatment Court is to be conducted in 2012. (Shatter 2011, 15 June).
In late July 2011, the Courts Service and the HSE agreed to extend the catchment area
for the DTC to all areas of Dublin County, north of the River Liffey and also to make it
accessible to those receiving treatment in the Castle Street drug treatment centre,
which provides services to people in Dublin 2, 4, 6 and 8. The extension of the
catchment area will be piloted for a period of six months, after which the capacity of the
court to manage a further extension will be considered (Tom Ward, chief clerk of the
Dublin Metropolitan District Court, personal communication, June 2011).
9.4.2
Other interventions in the criminal justice system
White paper on crime
The Department of Justice, Equality and Law Reform published the fourth and final
document in its consultation leading to the development of a White Paper on crime
(Department of Justice Equality and Law Reform 2010a). The White Paper, due to be
completed in 2011, will provide a high-level statement of government policy, its
rationale and the strategies to give effect to that policy. The process of consultation
involved the publication of four thematic discussion documents: Crime prevention and
community safety; Criminal sanctions; Organised and white collar crime; The
community and the criminal justice system.
9.5
Drug use and problem drug use in prisons
Please refer to Selected Issue in Chapter 11
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10.
Drug Markets
10.1
Introduction
The first comprehensive study of illicit drug markets in Ireland is due to be published by
the National Advisory Committee on Drugs (NACD) and the Health Research Board
(HRB) in late 2011. A detailed summary of the relevant findings from this study are
presented in this chapter. Data from several other information sources which give
indications of the nature and size of the market are presented where available.
Prevalence surveys may ask respondents about their access to illicit drugs and about
the availability of various drugs. For example, the all-Ireland general population drug
prevalence survey, described in detail in Section 2.1 of this report, asks respondents
how they obtained individual substances (who from and under what circumstances),
where did they obtain them (in what type of location) and how easy were they to obtain.
The European School Survey Project on Alcohol and Other Drugs (ESPAD), also
described in detail in Section 2.1 above, contains a question, the answer to which
indicates the perceived availability of some illicit substances – ‘How difficult do you
think it would be for you to get each of the following (cannabis, amphetamine,
ecstasy)?’.The above studies are not reported in every National Report.
Data on drug seizures by Customs Drug Law Enforcement (CDLE) and the Garda
Síochána provide insights into the origins of drugs being brought into Ireland, and the
nature of the market in terms of supply and availability. However, these data must be
treated with caution as the number of drug seizures in any given period can be affected
by such factors as law enforcement resources, strategies and priorities, and by the
vulnerability of traffickers to law enforcement activities.
Drug offence data published by the Central Statistics Office (CSO) can assist in
understanding aspects of the operation of the illicit drug market in Ireland. With regard
to the so-called middle market level, which involves the importation and internal
distribution of drugs, data on drug supply offence prosecutions by Garda division are a
possible indicator of national drug distribution patterns. While these data primarily
reflect law enforcement activities and the relative ease of detection of different drugs,
they may also provide an indicator of national drug distribution trends. These data can
be compared with other sources such as drug treatment data, for example, to show
trends in market developments throughout the State. Such data can also indicate
trafficking patterns by showing whether there is a concentration of prosecutions along
specific routes.
For policing purposes Ireland is divided into six regions, each of which is commanded
by an Assistant Commissioner. The six regions are:
 Dublin Metropolitan Region
 Northern Region
 Western Region
 Eastern Region
 Southern Region
 South Eastern Region
Each region is divided into divisions commanded by a Chief Superintendent, and each
division is then divided into districts commanded by a Superintendent, who is assisted
by a number of Inspectors. The districts are divided into sub-districts, each normally the
responsibility of a Sergeant.
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Map 10.1.1 Irish Garda regions and divisions
The Forensic Science Laboratory (FSL) provides impartial scientific evidence
following examination of crime scenes, including seizures of drugs. However, not all
drugs seized by the law enforcement agencies (the Garda Síochána or Customs Drug
Law Enforcement) are necessarily analysed and reported on by the FSL. For example,
if no individual is identified in relation to the drug seizure, and no prosecution takes
place, the drugs may not be sent for analysis and may be destroyed. Moreover, drug
purity data are not collated in a systematic way at different market levels in Ireland. The
primary function of the FSL in this area relates to supporting the criminal justice
system, and not to research. Only a very small proportion of drugs seized are tested to
ascertain the percentage purity.
10.2
Availability and supply
10.2.1 Perceived availability of drugs, exposure, access to drugs e.g. in general
population, specific groups/places/settings, problem drug users
A study commissioned by the National Advisory Committee on Drugs (NACD) reported
findings in relation to drug use among 479 early school leavers and 512 school
attendees aged 16–18 years, and identified risk and protective factors for substance
use. Data were collected throughout Ireland in March–May and September–December
2008. The participants were interviewed face-to-face. A second questionnaire on the
attributes of the schools or education centres was completed by the school principal or
education/training centre manager. Among both early school-leavers and school
attendees, rates of cannabis and other drug use were significantly higher where access
to the specific drug was easier (Haase and Pratschke 2010).
An online survey asked 329 ‘legal high’ users where they sourced new psychoactive
substances (Kelleher, Cathy, et al. 2011). So-called ‘head shops’ were most often
reported as the source. The study found that the proximity of head shops to users’
homes was likely to facilitate this: at the time of the survey, 65% (146) of respondents
had access to a head shop within 5km of their home. ‘Legal highs’ were also sourced
online by 16.5% (43) of respondents, from a ‘dealer’ by 12.2% (40), and through a
home delivery service by seven respondents.
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10.2.2 Drugs origin: national production versus imported
No new information available. See 2010 National Report for latest data (Irish Focal
Point 2010). See below for recent activities of Customs Drug Law Enforcement as
described in illicit drug market study (Connolly and Donovan In press).
10.2.3 Trafficking patterns, national and international flows, routes, modi
operandi; and organisation of domestic drug markets
Figures 10.2.1.1 and 10.2.2.2 below show the trends in relevant legal proceedings for
possession of drugs by Garda region between 2003 and 2009. It should be noted that
possession includes possession for personal use and possession for the purpose of
supply. It is not possible to distinguish reported data for these two offences by gardaí
region. However, as shown in Table 9.2.1.1 above, it is generally the case that
between 70% and 75% of all possession cases are for personal use.
3500
3000
2500
Number
2000
1500
1000
500
0
2003
2004
2005
2006
2007
2008
2009
Southern region
1026
1214
1628
1560
2208
2996
2815
South eastern region 1624
977
1287
1405
1540
1733
1787
Eastern region
1201
929
1517
1274
1715
2126
1854
Northern region
442
351
450
629
782
873
955
Western region
390
429
464
609
747
848
708
Figure 10.2.1.1: Trends in relevant legal proceedings for possession of drugs by Garda region
excluding the Dublin Metropolitan Region 2003–2009.
Source: (Central Statistics Office 2008) (Central Statistics Office 2011)
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16000
14000
Number
12000
10000
8000
6000
4000
2000
0
State (total)
Dublin Metropolitan Region
2003
4987
2810
2004
5414
1514
2005
7846
2500
2006
8422
2945
2007
2008
2009
11074 13855 12814
4082
5279
4695
Figure 10.2.2.2: Trends in relevant legal proceedings for possession of drugs for the Dublin
Metropolitan Region and total possessions for the State 2003–2009
Source: (Central Statistics Office 2008) (Central Statistics Office 2011)
The two figures show that the trend in prosecutions for possession decreased in most
garda regions in 2009, after a steady increase since 2006. The only regions that
showed a continuous increase were the Northern and South Eastern regions. The
Dublin Metropolitan Region (DMR) still accounts for the majority of possession
prosecutions in the State. However, a comparison of the data for 2003 and 2009 shows
that the proportion of prosecutions outside the capital has increased significantly. In
2003, the DMR accounted for 56.3% of the total number of possession prosecutions in
the state, and 36.6% in 2009. These data show that the drug phenomenon is now more
widely distributed throughout the state.
An ethnographic study of drug use in the Canal Communities area of Dublin
The Canal Communities Local Drugs Task Force (CCLDTF) covers the areas of Rialto,
Bluebell and Inchicore in the Dublin 8 area. The CCLDTF undertook a study to improve
knowledge and understanding of the nature of illicit drug use in their area (Saris and
O'Reilly 2010).
The researchers used an ethnographic approach, incorporating a range of research
methods to describe and explain how specific groups of people experienced and
perceived their lives and surrounding environment. Data for the CCLDTF study were
collected by means of participant observation (in service facilities, estates, homes) and
through interviews. Fifty-one interviews were conducted, of which 24 were life histories
and eight were group discussions (with 29 young people). Six of those who were
initially interviewed had a subsequent interview. Additionally, there were 24 formal and
informal interviews with service providers. Interviewers also administered a survey to a
target population of 100 opiate or methadone users.
The report of the study begins with a discussion on the nature of drug use and the
difficulties in relation to the categorisations used within the field. In relation to patterns
of use, the authors use the term ‘styles’ as this can help convey how ‘…at any one
moment, populations that overlap certain institutional categories (disorganized heroinusers, for example, can be found both in and out of treatment, often using both
methadone and heroin simultaneously), while presenting different challenges to various
intervention strategies’ (p. 19). This is followed by a chapter which discusses
experiences of the combined use of heroin and methadone in the CCLDTF area.
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Subsequent chapters deal with the history and the issues around drug use in the area,
the emergence of crack cocaine and the changing patterns of drug use. Data from the
Central Treatment List (CTL) pertaining to people living in the CCLDTF area were
analysed. One finding from this analysis was that the area had a relatively high rate of
registration on the CTL in 2007, at 20 per 1,000 of the population, compared to 2 per
1,000 of the population nationally.
The quantitative data collected from 98 valid responses to the survey administered to
opiate and methadone users are summarised in an appendix to the report. The main
results include:
 63% were male;
 98% were prescribed methadone;
 Average number of days on methadone was 86;
 63% reported current use (last three months) of heroin;
 46% reported current use of street benzodiazepine;
 30% reported current use of crack;
 22% reported current use of powder cocaine;
 17% reported current use of street methadone;
 60% of those who injected reported sharing a needle or syringe;
 36% reported spending between €60 and €119 on drugs in the average week;
 88% reported ever having been involved in crime;
 57% reported having had a custodial sentence.
Most of those interviewed for the study were polydrug users, often using combinations
of illegal and legal drugs (whether obtained legally or not). Many of those who took
part in the study and who were in treatment for opiates also used cocaine, with the use
of crack cocaine emerging as a problem. Individuals who dealt drugs often continued to
do so after entering treatment. The study provides a useful insight into a local drug
market involving a range of both licit and illicit drugs. Drug markets for different
substances are often seen as distinctive, with those who supply and those who use
drugs seen to specialise in particular substances, for example heroin or cannabis
(Connolly and Donovan In press). This study, by highlighting the issue of polydrug use
in a small community, raises questions as to the nature of local drug supply. Further
research focussing on drug supply sources would be useful.
Study of Illicit drug markets in Ireland
The first comprehensive study of the Irish illicit drug market is due to be jointly
published by the NACD and the Health Research Board in late 2011(Connolly and
Donovan In press). The following is a summary of the main findings.
Study aims
The aims of the study were to:
 examine the nature, organisation and structure of Irish drug markets,
 examine the various factors which can influence the development of local drug
markets,
 examine the impact of drug dealing and drug markets on local communities, and
 describe and assess interventions in drug markets with a view to identifying what
further interventions are needed.
Methodology
The research was carried out in four locations: two sites in urban areas, one in a
suburban area and one in a rural area. These sites varied considerably in terms of
population and geographic location. The basic selection criteria were that the areas
should be sufficiently varied to provide a cross-section of illicit drug markets in Ireland.
The electoral divisions within the study sites chosen were those where deprivation
levels were high (based on proportion of over-15s unemployed, proportion of
population in social class 5 or 6, proportion of households with no car and proportion of
rented or local authority housing). Data on the proportion of residents who had served
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prison sentences for drug offences were also used as an indicator. The identities of the
study sites were concealed so as not to consolidate their reputation as illicit drug
market locations. Site A is located within a suburban satellite town with a population of
approximately 40,000. Site B is a rural site encompassing just two electoral divisions –
one representing the town, with a small population of 2,000–3,000 and the second
representing the population of the rural hinterland, with a population of 10,000–11,000.
Site C is an urban site, encompassing 20 electoral divisions, with a population of
30,000. Site D is an urban site encompassing 19 electoral divisions with a population of
some 60,000.
The study was conducted over an 18-month period (June 2008 — December 2009)
using a mixed methodological approach, including:
 individual, face-to-face, in-depth interviews with both former and active drug users
and street sellers;
 interviews with individuals serving prison sentences of more than seven years for
drug supply;
 interviews with experienced members of dedicated Garda drug units in the four
study sites and with senior members of the Garda National Drugs Unit;
 interviews with drug treatment workers and a public health specialist;
 a street survey of 816 local residents and people working in the area
(approximately 200 respondents in each location).
Criminal justice data analysed included drug offence data for the period 1 October
2008 to 31 March 2009 obtained from the Garda Síochána PULSE Information
Technology system (Police Using Leading Systems Effectively). PULSE includes
information on the number of drug seizures, the profile of offenders and the
circumstances of arrest. Data on over 1,200 cases were collected from 12 Garda
stations in the four study sites, and data on seizures made by CDLE, collected from 18
stations nationwide over a six-month period (January–June 2009), were analysed.
Main findings
Factors which can influence the development of local drug markets
Most survey respondents highlighted social issues as the main reasons for local drug
use, including the absence of facilities for young people, high unemployment, boredom,
poor parental supervision and drug availability. Additional factors identified through indepth interviews included the relocation of people from deprived urban centres to
suburban and rural areas and, in one location, the influence of a local prison where
people had developed addictions and/or met people who had subsequently introduced
them to drug dealing. The arrival of people, both national and non-national, had also
contributed to the development of markets for drugs such as herbal cannabis, heroin
and crack cocaine. Senior experienced members of the Garda National Drugs Unit
describe the illicit drug market in Ireland as involving a series of sometimes overlapping
markets for different substances which have evolved in waves or phases over the past
three decades, with the heroin market, for example, beginning in the centre of Dublin
and gradually spreading throughout the country.
The cannabis market is described as geographically dispersed and continuously
growing, while the ecstasy market is distinctive in that it emerged in the early 1990s
and spread throughout the country very rapidly over an 18-month period. Previously,
cocaine use was generally regarded as being confined to specific sectors of the
population and specific locations, possibly given the higher prices associated with it.
However, the decade of rapid economic growth up to 2008 saw cocaine use spread
widely throughout the country. Crack cocaine is a relatively recent phenomenon, which
emerged in north Dublin inner city and has now spread throughout the capital and
beyond.
The nature, organisation and structure of Irish drug markets
There is no simple way to describe the organisational nature of the various drug
markets examined as they differed widely in terms of their levels of structure and
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organisation throughout all four study sites. Site D, for example, was referred to as
highly structured with regard to the distribution of heroin, cocaine and cannabis and
involving three to four levels of distribution. Several high-level suppliers were involved
in drug importation and distribution over a very wide area. The middle market in this
location was reportedly heavily populated by individuals and groups or ‘gangs’
supplying drugs in volumes of kilograms or more. Site D also had several highly visible
open street-level markets where heroin, crack cocaine and prescription drugs could be
purchased. Although crack cocaine had originated with West Africans, it now involved
more Irish sellers. Closed markets in pubs and flat complexes were also reported. Site
A also had a visible and busy open street-level market for crack cocaine, where dealers
took turns to sell drugs to buyers who often came from outside the area.
Site B also attracted non-local buyers to purchase heroin. The heroin supply here was
regarded as having originated within families but to have involved more recently a
looser network of individuals. Heroin was not directly imported but sourced from the
major cities of Dublin and Limerick. Cocaine distribution in this market was more
structured and lucrative and dominated by a particular group of individuals who used
legitimate businesses as a means of transporting drugs throughout the region. Streetlevel distribution was closed, with transactions made over the phone, deliveries made
to people’s homes and contacts formed through trusted third-party introductions. In site
C, the distribution of drugs such as cannabis and cocaine was concentrated among a
small number of established families. Heroin distributors were described as non-local,
both Irish and non-Irish, who had arrived in the area with an addiction. The heroin
market was also described as less structured and easier to penetrate from a law
enforcement perspective. Although this was a large urban area, there was no open
street market reported, with drug transactions arranged via mobile phone and at prearranged locations.
In site A, a large number of individuals performed roles on behalf of higher-level
suppliers, including the dilution or preparation of drugs. Those involved in the storage
and transport of drugs were generally relatively minor participants in the drug supply
chain, either earning drugs for their own use or trying to pay off a drug debt. Young
people also played a substantial role in drug distribution at street level. Storing or
running drugs was a financially lucrative option for teenagers. PULSE data revealed
that, over a six-month period, one fifth of suspected supply offenders were aged 18 or
under. Many of these young people were reportedly from unstable home environments.
The profile of runners was different in site B. They were often older heroin addicts
running drugs in return for a personal supply. Non-drug-using young people (aged
under 18) were not reported as playing a significant role in drug distribution. Similarly,
in site C, although runners did exist, there was little evidence to suggest the
involvement of very young people (aged 16 and under). It was reported that this would
not have been tolerated locally by residents. By contrast, in site D, young people (aged
under 16) were reported to be heavily involved in running drugs.
Description of interventions in drug markets
This study provides the first comprehensive picture of the role, resources, strategies
and activities of the principal drug law enforcement agencies in the State – CDLE and
the Garda Síochána. CDLE reported a number of successful operations during the
period of the research. Of the 1,378 seizures of illegal or controlled drugs between
January and June 2009, 90% were of cannabis herb or resin. The vast majority of
these seizures (90%) weighed less than 28g and were most likely for personal use. In
the same period, 52 seizures were made by CDLE of illegal substances that weighed
1kg or more (4% of total seizures). Cocaine and cannabis herb accounted for 89% of
these seizures. It is not possible to determine accurately the proportion of these drugs
that were destined for the Irish market or whether these seizures had a significant
impact on drug availability in Ireland.
Garda National Drugs Unit (GNDU) strategic operations focus on dismantling and
disrupting international and national drug supply networks and organisations and also
131
working with divisional and district Garda drug units to dismantle local networks. The
GNDU also co-operates with CDLE and with international organisations. The GNDU
also has a role in co-ordinating Garda policy on demand reduction initiatives. The
gathering and collation of reliable intelligence is central to the success of the work of
the GNDU. Unlike other areas of policing, such as robbery or murder, investigations
cannot always begin from a crime scene but must depend on intelligence. In recent
years the Central Human Intelligence System (CHIS) has been developed. This
provides a structure whereby all intelligence is now centralised within a specific unit.
The GNDU also manages undercover test purchase operations, to penetrate closed
retail markets or recreational markets such as nightclubs where people are less likely
to deal drugs to strangers. In all research sites Garda drug unit strategy involved a
combination of activity targeting both street dealing and higher-level suppliers.
Intelligence was generally acquired through developing relationships with offenders
working in the lower levels of distribution. In site C, a divisional drug unit sought to
disrupt higher-level supply lines, while district policing tended to focus on local low-level
sellers.
Assessment of interventions
In the previous and current National Drugs Strategy, the key performance indicators
under the supply reduction pillar focus on increasing supply detections and drug
seizure volumes (Department of Tourism Sport and Recreation 2001) (Department of
Community Rural and Gaeltacht Affairs 2009). Both Customs Drugs Law Enforcement
and the Garda Síochána have surpassed their required targets in this respect,
reporting a number of successful operations during the period of this research.
However, one of the challenges from a law enforcement perspective highlighted in this
study relates to the difficulty of identifying any clear link between supply reduction
activity and drug availability and use. The absence of reliable evidence of a
straightforward link between supply reduction initiatives and sustained reductions in
drug availability has been highlighted in the international literature and was also
identified as an important issue during the preparation of the current National Drugs
Strategy.
Despite the difficulties associated with policing drug markets, research and evidence
suggest that supply reduction activities can contribute to the containment of drug
markets and frustrate the expansion of new markets. Nevertheless, the public demand
for illegal drugs and the profits which can be earned from drug dealing ensure that
international and Irish drug markets remain resilient and adaptable to law enforcement
interventions. Across all four study sites, supply offences accounted for between 17%
and 33% of all drug offences. The largest proportions of supply offences were in sites A
and D, which had a number of open drug markets. Most supply offences related to
heroin, cocaine and crack cocaine. On the one hand, this reflects the intelligence-led
and focused nature of activity by individual Garda drug units. On the other, it reflects
the greater availability of drugs in these areas. In all four sites, most prosecutions were
for simple possession of cannabis. Most of these relate to stop and search activity by
Garda members, and the amounts seized were valued at between €10 and €20.
Although some drug sellers acknowledged the importance of being wary of Garda
activity, there is no evidence from the study that general drug availability was
significantly affected for any period by law enforcement. Local community tolerance of
cannabis use was highlighted by Garda members and by treatment workers in a
number of sites. In sites A and D, the gardaí had initiated several targeted operations.
Despite this, gardaí acknowledged that, although their activities led to the disruption of
the market, the impact was generally of short duration as markets quickly adapted.
Again, this is consistent with findings from international research. The limitations of
such Garda crackdowns in busy hotspots were also highlighted by local drug sellers,
who explained that they would disperse quickly when gardaí approached and resume
when they left the area. Drug sellers also adapted to drug law enforcement by
managing risk exposure. Rather than keeping drugs on their person, they were kept in
a separate location. Consignments might be divided up and buried at a series of
132
locations, where buyers could collect them. Higher-level sellers often used others to
transport drugs for them, either children or people who were in debt to them, or heroin
users who did it in return for drugs for their own consumption. Drug sellers also
reported using people as decoys, giving them a small amount of drugs and then
informing the gardaí so as to distract the latter from a larger drug deal happening
simultaneously.
Although relations with communities and other agencies, including treatment agencies,
were stronger in some locations than others, in general, inter-agency and community
links were underdeveloped and often informal. However, formalised community and
inter-agency partnerships, where they existed, were regarded as beneficial both in
terms of developing responses and reassuring community residents.
Community perspectives
In site A, only one third of survey respondents believed the gardaí to be effective or
very effective in dealing with crime. Just over a quarter of residents knew a Garda
member by name. In site B over half of survey respondents believed the gardaí to be
effective/very effective in dealing with crime in their area. More than half of the
residents surveyed knew a Garda by name and 42% had spoken to a Garda about
their area. In site C almost half of survey respondents believed the gardaí to be
effective/very effective in dealing with local crime. More than a third of respondents
knew a Garda member by name and/or had spoken to them about the area. In site D,
just under half of respondents believed the gardaí to be effective/very effective in
dealing with crime. Just one quarter of respondents knew a Garda member by name
and/or had spoken to them about the area. These findings suggest that there may be a
link between perceptions of Garda effectiveness and positive engagement with
individual Garda members working in the community. Sites A and D also had visible
open street level markets and this could have an effect on community perspectives of
Garda effectiveness. In all four sites, the most prevalent reason for not reporting
information about drug-related activity to gardaí related to fear of reprisal from those
involved in drug-related crime.
Unintended consequences of law enforcement
In all four sites, gardaí highlighted the importance of using informants for the purposes
of intelligence gathering. However, this could also have unintended consequences. The
use of informants by the gardaí was regarded by sellers as a major source of suspicion
which often led to violence in drug markets. It was also pointed out by the GNDU that
some of the violence in drug markets that was associated with Garda seizures or
arrests arose as a result of paranoia among drug suppliers. In all four sites, most of the
violence that occurred related to unpaid drug debts. Drug debts were acquired through
people consuming their own supply or as a result of Garda seizures. Where gardaí
seized drugs, debts remained outstanding and still had to be paid. This may be
described as an unintended negative consequence of drug law enforcement, whereby
effective supply reduction activities can indirectly contribute to greater levels of drugrelated violence. Another unintended effect of law enforcement identified in the
literature is the tension that can arise between law enforcement and public health
goals. For example, where drug markets develop in close proximity to drug treatment
centres, law enforcement responses need to be carefully managed. Sensitivities in
relation to this issue were acknowledged both by health workers and by Garda
members interviewed in one study location, and the gardaí adopted a pragmatic
approach when dealing with dependent drug users seeking treatment. This highlights
the importance of nurturing and sustaining effective partnerships between criminal
justice, health and social agencies.
Policy implications
The following is a discussion of the some of the main policy implications arising from
the research.
133
Preventing the emergence and growth of illicit drug markets
Future approaches to illicit drug markets and drug-related crime need to address the
various environmental, social and economic factors that contribute to the emergence
and growth of illicit drug markets in the first place. These factors should be considered
in relation to different market levels: import, middle-market and retail level. Preventative
approaches should involve collaboration with international partners in countries where
the drugs are sourced. At national level, environmental crime prevention measures
should be incorporated into housing planning, for example. In seeking to prevent young
people from becoming involved in gang formation and local drug markets in the future,
international best practice approaches need to be investigated and delivered through
the education system. In responding to illicit drug markets, it is important to consider
what interventions are seeking to achieve and how specific market structures and
forms of organisation can impact on these interventions. Policing responses, whether
street patrols or intelligence-led initiatives of a more covert nature, strive to disrupt
markets and thus reduce or control supply. On the other hand, demand-reduction
strategies attempt to target users and divert them into drug treatment, by means of
arrest referral schemes, for example. It is important that supply reduction and demand
reduction initiatives are complementary.
The international literature also suggests that time in prison may contribute to future
involvement in illicit drug markets. Although this issue was not the focus of this
research, a number of interviewees in particular sites referred to the fact that the prison
setting had afforded them the opportunity to make friends/acquaintances with people
with whom they subsequently, upon release, engaged in drug dealing. These
interviewees were often dependent drug users whose original imprisonment was drugrelated. This reaffirms the desirability of diverting people away from imprisonment,
where appropriate, and into treatment. The increased use of arrest referral and the use
of alternatives to imprisonment such as the DTC provide a more humane, effective and
sustainable approach. In addition, this issue highlights the importance of supporting
further efforts in the provision of treatment while in prison.
Directing responses towards the specific characteristics of the illicit market to focus on
the individuals and markets that cause greatest harm
When asked what was needed to reduce drugs and crime in the area, the majority of
respondents to the street survey across all four sites called for more gardaí patrolling
on the streets. Visible policing can help alleviate some of the fears associated with
local drug markets. Regular police patrolling can also disrupt open drug markets and
cause them to move continuously so that they do not gain a permanent visible
presence. This can make the markets less accessible to people who may wish to
experiment with drug use and it can alleviate the corrosive effect that open drug scenes
can have on local community morale and local businesses. A regular visible police
presence is also very important in fostering interaction between the gardaí and the
local community, as community members become familiar with individual Garda
members. Formalised meetings between the gardaí and local residents can benefit
from such interaction.
The main newly emerging drugs identified in specific study locations were crack
cocaine, cannabis herb and benzodiazepines. Each of these drugs raises different
issues from a legal regulation and law enforcement perspective and also in terms of the
harms associated with them. Clearly, the open dealing of crack cocaine and heroin that
was identified in this study in sites A and D is particularly harmful to the local
communities. Public displays of drug-market violence and the involvement of young
people in drug distribution are also particularly harmful consequences of some of the
drug markets studied here. The deployment of law enforcement and other resources
towards addressing and alleviating these most harmful drug markets, and the
limitations in available resources, indicate the need for strategic use of resources.
A similar sense of perspective should also inform criminal justice responses to those
involved in the operation of illicit drug markets. This study highlights the reality that
drug-dealing enterprises are dependent on the participation of numerous individuals
134
performing different roles. These include people exploited by high-level drug dealers to
hold or transport drugs, such as children, dependent drug users or non-nationals from
low-income countries. Although the ultimate harm to society arising from the supply of
those drugs may be the same regardless of the motivation of the individual involved,
effective prevention policies need to address the circumstances which lead people to
become involved in illicit drug markets in the first place. Similarly, consideration needs
to be given to cases in which individuals are found in possession of only a small
quantity of drugs, but where other evidence suggests that they are dedicated high-level
drug dealers.
For example, the issue of sentencing, although not covered in detail in this study, did
arise, particularly in relation to the imposition of the mandatory minimum sentence
provided for in the Criminal Justice Act 1999 (see Section 1.2.2 above). In deciding
whether or not to impose the mandatory 10-year minimum sentence for drug
possession as provided for in this legislation, the courts must consider and respond to
many complex issues arising as a consequence of the operational dynamics of illicit
drug markets. Further information about the nature of these issues and their broader
societal and criminal justice implications would be of value. Ultimately, the importance
of developing successful interventions at the highest levels of the illicit drug market
should remain a core focus of policy.
Building community confidence and partnership responses
There is growing evidence, both internationally and in Ireland, that partnership
approaches involving local communities, state agencies and other stakeholders offer
the most effective method of responding to many drug problems, including illicit drug
markets. Community engagement in partnership approaches is often contingent,
however, on the extent to which community concerns are understood and acted upon.
In trying to develop the capacity of communities to take positive action against drug
markets, it is important to appreciate the limited or constrained choices that are open to
many community residents. In particular, the fear and intimidation associated with drugrelated crime clearly undermines the willingness of the public to engage with initiatives
aimed at disrupting such markets. Consequently, successful approaches depend upon
the building of community confidence through initiatives that are locally relevant, that
are tangible and that are consistent over time. Such a response can best be delivered
through formal inter-agency and community-based structures such as local policing
fora, as provided for in the National Drugs Strategy 2009–2016 (Department of
Community Rural and Gaeltacht Affairs 2009). The prioritisation of community issues,
the implementation of responses with community support and engagement and the
fostering of more effective relations between agencies can help ensure that public and
human resources are used to their maximum effect.
Investigating drug markets and monitoring drug market interventions
It is necessary to continue to develop methods to improve knowledge about illicit drug
markets, supply reduction activities and drug-related crime in line with international
best practice. Despite Irish research clearly indicating that many arrested and
imprisoned offenders are dependent drug users, the absence of accurate indicators to
assist in measuring the proportion of crime committed as a consequence of drug use is
a major gap in knowledge and undermines the development of evidence-based
responses to drug-related crime.
This study shows that regular compilation of drug market data, including data on
arrests, seizures, price and purity, and adulterants, can assist in explaining both the
operational dynamic of illicit drug markets, and can be useful in monitoring and
informing both criminal justice and public health responses to them. The regular
compilation of such data at different market levels and for different drug types will
further enhance this picture. However, a more comprehensive understanding of drug
markets, drug-related crime and supply reduction responses requires such data to be
complemented by other data sources and further research. The full impact of supply
reduction activity, for example, cannot be fully assessed by measuring arrests and
135
seizures alone or through proxy measurements such as price and purity. A fuller
picture needs to incorporate demand reduction, social, health and community welfare
indicators. Although this exploratory study has sought to develop our understanding of
illicit drug markets in Ireland, as with most research it has also identified areas where
further investigation is warranted. The pathways that lead young people into drug
dealing and drug-related gangs, developing our understanding of higher-level drug
markets in association with international partners, and recreational drug markets which
are less likely to come to police attention are just some potential areas for further
research.
Conclusion
The complete removal of illicit drug markets through drug law enforcement is not an
achievable goal in the foreseeable future. It needs also to be recognised, however, that
not all drug markets are equally harmful in terms of the effect they can have on
individuals and local communities. For example, some are more violent than others and
open markets cause more disruption to communities than closed ones. Some involve
the exploitation of young people and other vulnerable groups. Future law enforcement
interventions, in partnership with communities and other agencies, need to evolve to
address the complexities and particular harms associated with Irish drug markets. It is
suggested that such an approach requires a more pragmatic use, co-ordination and
streamlining of existing resources and the targeting of those resources at the most
harmful aspects of Irish drug markets. Law enforcement interventions that focus on the
particular harms associated with an individual market have the potential to have an
impact on those harms and they may also lead to a more effective use of public
resources. Also, approaches which seek to divert problematic drug users into treatment
and which prioritise local community perspectives, and those which occur in
collaboration with other relevant agencies, are more likely to be sustainable over time
and to win public support. Finally, it is necessary to develop our understanding of illicit
drug markets and drug-related crime and of the interventions made in response to
them through an integrated approach, by promoting research and monitoring systems
which can enable us to analyse such phenomena and activities across both state and
community sectors.
10.3
Seizures
10.3.1 Quantities and numbers of seizures of all illicit drugs
The number of drug seizures in any given period can be affected by such factors as
law enforcement resources, strategies and priorities, and by the vulnerability of
traffickers to law enforcement activities. However, drug seizures are considered indirect
indicators of the supply and availability of drugs (See Standard Table 13).
Cannabis seizures account for the largest proportion of all drugs seized. Figure
10.3.1.1 shows the trend in cannabis-related seizures and total seizures between 2003
and 2010. The total number of drug seizures increased between 2005 and 2007, then
decreased in 2008 and again in 2009. In 2010 the number of seizures appears to have
levelled out. This decrease and levelling out in total seizures between 2008 and 2010
can be explained partly by the trend in cannabis seizures during the same period. In
2009 there were fewer reported cannabis seizures (n = 2,314) than in 2005 (n = 3,555).
In 2010, there were 2,268 cannabis-related seizures, a slight decrease from 2009. It is
not clear whether the reduction in cannabis-related seizures reflects a decline in
cannabis use or a reduction in law enforcement activity targeted at the cannabis
market. However, it should be noted that drug offence prosecutions reported in Section
9.2 above, most of which are cannabis-related, also decreased slightly in 2009, with
figures for 2010 not currently available.
136
12000
Number
10000
8000
6000
4000
2000
0
2005
2006
2007
2008
2009
2010
All seizures
6362
8417
10444
9991
5494
5477
Cannabis-type substances 3555
4243
5176
5652
2314
2268
Figure 10.3.1.1 Trends in the total number of drug seizures and cannabis seizures, 2005–2010
Central Statistics Office 2008, 2009, 2010; (An Garda Síochana 2011)
The reduction in the total number of reported seizures in 2009 and its levelling off in
2010 may also be explained by a reduction in the number of seizures of other drugs
since 2008. Figure 10.3.1.2 shows trends in seizures for a selection of drugs, excluding
cannabis, between 2003 and 2010. There has been a significant decline in seizures of
cocaine, heroin and ecstasy-type substances since 2007. It appears that the significant
reduction in total drug seizures reported in 2009 can be explained primarily as the
result of a reduction in seizures of cannabis and cocaine. However, in 2010 we have
seen the continued decline in heroin seizures. It is unclear whether this reflects a
decline in heroin use or a change in law enforcement activities or some other factor.
2000
1800
Number
1600
1400
1200
1000
800
600
400
200
0
2003 2004 2005 2006 2007 2008 2009 2010
Ecstasy-type substances 1083
806
689
858
1173
730
90
30
Heroin
660
612
763
1254 1698 1611 1455 1150
Cocaine
566
753
1045 1500 1749 1310
635
588
Amphetamines
211
145
125
277
235
126
72
89
Figure 10.3.1.2 Trends in the number of seizures of selected drugs, excluding cannabis, 2003–2010
Central Statistics Office 2008, 2009, 2010; (An Garda Síochana 2011)
* Includes MDMA, MDEA, and DOB
Table 10.3.1.1 shows the particulars of all drugs seized in 2010 that were reported on
by the FSL. As noted in Section 10.1 above, not all drugs seized by law enforcement
agencies (the Garda Síochána and CDLE) are necessarily analysed and reported by
137
the FSL. The FSL advises that there may be some cases, comprising large quantities
of cannabis / cannabis resin, where a suspected offender has not been identified,
which have not been subject of detailed analysis by the FSL and for which a specific
weight has not been determined.
Table 10.3.1.1Particulars of all drugs seized in 2010 that were reported on by the Forensic Science
Laboratory
Drug
Quantity
Cases
(number)
Alprazolam
70,183 tablets
98
Amphetamine
26,462.894 grams
89
BK-MBDB
91 capsules 34 tablets,63.282 grams
16
Buprenorphine
33 tablets
3
BZP ***
351,536 tablets, 3,271.406 grams, 371
348
capsules
Cannabis
912,961.766 grams
1247
Cannabis resin
748,265.893 grams
616
Cannabis plants*
3,851 plants
405
Chlorpheniramine **
204 tablets
1
Clonazepam
100 tablets
12
Cocaine
94,804.200 grams
588
CPP **
5 tablets
3
Diamorphine (Heroin)
30,158.017 grams
1150
Diazepam
145,197 tablets, 11,522.777 gram
448
Dihydrocodeine
434 tablets
12
Ephedrine
3,926 tablets 22.461 grams
15
Ecstasy MDMA
398 tablets, 1,428.636 grams
30
Flephedrone
811.005 grams
7
Flunitrazepam (Rohypnol)
1,009 tablets
9
Fluoxetine**
2 capsules
1
Flurazepam
1,505 capsules, 21 tablets
37
Ketamine
83.742 grams
11
Khat
Plant samples
2
Lignocaine**
13,993.120 grams
39
Lorazapam
230 tablets
5
LSD
1,588 squares, 57 tablets
13
Mephedrone
5,298.420
100
Methandienone**
22 tablets
2
Methadone
4,801 mls
33
Methylamphetamine
404.162 grams
20
Oxymetholone**
733 tablets
15
Prazepam
2 tablets
1
Sildenifil**
234 tablets
20
Stanozolol**
310 tablets
4
Temazepam
244 tablets
9
Triazolam
130 tablets
12
Zolpidem**
53 tablets
10
Zopiclone**
49,170 tablets
138
*The number of cannabis plants does not reflect the total number detected as only a sample of the plants are sent for analysis for
practical reasons.
**These drugs are not controlled under the Misuse of Drugs Acts, 1977 & 1984.
*** BZP was controlled on 31 March 2009.
Prison drug markets
Data on prison drug markets such as the number and volume of drug seizures; price
and purity data are not routinely collected or reported. However, the data presented in
Table 10.3.1.2 was provided by the former Minister for Justice, Equality and Law
Reform in response to a Parliamentary question in late 2010. Most of the seizures
reported were made at entry to the prison, during prison visits for example, and
consequently the drugs did not enter the prison system. The Minister also explained
that ‘prior to May 2008 seizures of drugs were recorded under the generic description
“prohibited articles” and accordingly a detailed breakdown is not available.’ (Ahern,
Dermot 2010, 28 October) Once suspected drug seizures are made by prison staff,
according to the former Minister, ‘as Prisons do not have the facilities to test the type or
quantity of substances found, gardaí (police) are contacted...and issues for
investigation and prosecution fall within their remit’.
138
Table 10.3.1.2 Drug seizures in Irish prisons, January 2009–September 2010
Prison/Place of Detention
Number of Drug Seizures in
2009
Number of Drug Seizures in
2010 (up to 12/9/2010)
Arbour Hill Prison
Castlerea Prison
Cloverhill Prison
Cork Prison
Dóchas Centre
Limerick Prison
Loughan House
Midlands Prison
Mountjoy Prison (male)
Portlaoise Prison
Shelton Abbey
St. Patrick’s Institution
Training Unit
0
65
97
35
11
75
12
93
547
20
19
92
60
0
54
54
33
14
119
28
60
527
27
20
137
37
Wheatfield Prison
167
69
1,293
1,179
Total
10.3.2 Quantities and numbers of seizures of precursor chemicals used in the
manufacture of illicit drugs
See National report 2010 for most recent information (Irish Focal Point 2010).
10.3.3 Number of illicit laboratories and other production sites dismantled; and
precise type of illicit drugs manufactured there
See Section 10.4 in relation to the increase in detections of so-called ‘cannabis
factories’.
10.4
Price/purity
Study of cannabis THC in herbal cannabis
The FSL undertook a study of the tetrahydrocannabinol (THC - the psychoactive
ingredient in cannabis) content of a sample of cannabis resin and herbal cannabis
plants (home grown or imported) (see Standard Table 14) (Arnold In press). The study
was conducted in light of a reported increase in the discovery in recent years of socalled ‘cannabis factories’. The author describes how cannabis plants are cultivated in
these ‘factories’, using hydroponic and ultra violet light equipment; hydroponic systems
involve the growing of cannabis in nutrient solutions rather than soil. The author also
explains how herbal cannabis consists mainly of the ‘flowering and fruiting tops of the
female plant’ and is commonly known as ‘grass’, ‘weed’ or ‘marijuana’. The resinous
secretions of the cannabis plant can be collected to form ‘slabs’ of cannabis resin,
commonly known as ‘hash’.
The author reports an increase in recent years in the discovery of ‘huge’ operations of
so-called cannabis factories by the gardaí and a decrease in seizures of resin for the
purpose of supply. In order to fill the gap in knowledge about the potency levels of THC
in home-grown and imported cannabis varieties in Ireland, the author collected a
number of cannabis samples from seizures submitted to the FSL by the Garda
Síochána between October and December 2010. Twenty samples were analysed – 10
herb samples and 10 resin samples. Unlike the herb samples, most of the resin
samples analysed were small street samples used for personal use. The study
confirmed that a ‘huge’ increase in cannabis cultivation had taken place in Ireland and
that garda seizures indicated that cannabis herb appeared to be in greater demand
than resin.
139
The author asks whether the increased demand for cannabis herb is because there is a
shortage of resin or because there is more THC in cannabis herb. The study found that
the THC content in 10 cannabis resin seizures ranged from less than 1% to 5.4%,
while the THC content in eight suspected imports of cannabis herb was between 3.96%
and 13.34%, although in general there was ‘little variance in the THC concentration in
suspected imports’ (p. 12). The study acknowledges that only a small sample set was
analysed and that the THC content was lower than that found in other countries.
Illicit drug market study - Impact on drug price and purity
As part of the drug market study described in Section 10.2.1 above, data on drug
prices and profits made were obtained from interviews with those involved in buying
and selling drugs (Connolly and Donovan In press). Also, forensic analyses of drug
seizures in the study sites between 1 September 2008 and 28 February 2009 were
conducted by the FSL. Qualitative analysis was performed to identify the presence of
illicit substances. Quantitative analysis (drug purity) was then performed on powders
and tablets containing specific drugs, namely amphetamine, cocaine, diamorphine
(heroin) and MDMA, to determine the levels of purity of the illicit substances present.
The analysis also identified the other substances or adulterants present in the samples,
giving an indication of the typical bulking agents being used within the illicit drug
market.
10.4.1 Price of illicit drugs at retail level
Interviews suggested that heroin and cocaine had become cheaper to buy in all four
sites and at all market levels during the course of the study (see Standard Table 16).
However, crack cocaine prices remained high and steady in the markets where it was
available. Crack also returned the highest profit margins. Depending on the unit size
that they were willing to sell at, sellers could make between 200% and 400% profit on
their initial stake or investment. The amount of profit was affected by whether or not the
seller was a drug user, thereby consuming part of their own supply. Although there are
a number of factors that can impact on drug prices in an illicit market, there was no
indication from this study that drug law enforcement was having any effect on price
levels or profitability.
10.4.2 Price/potency of illicit drugs
Heroin purity levels varied within drug markets at all four study sites, but average purity
remained fairly consistent across all markets at around 45% (Connolly and Donovan In
press). This suggests that heroin markets, both urban and rural, were relatively stable,
with purity levels remaining constant. What this finding probably reflects is the reality
that heroin is no longer a primarily Dublin-based phenomenon but that there is a
consistent supply of heroin countrywide.
Cocaine purity levels were generally very low, averaging 14% across sites A, C and D.
It is unclear why this was the case. One might assume that low purity levels would be
an indicator of a decrease in availability, but other information sources, such as survey
data and treatment figures, do not suggest that there was a decline in cocaine use at
the time of the study. An important feature of the purity data in this study relates to the
adulterants used when mixing or diluting cocaine. The presence of lignocaine and
phenacetin in most cocaine seizures throughout all study sites suggests either the wide
availability of such substances or, the more likely scenario, that cocaine is most often
adulterated at the import stage of the market or prior to being imported. The presence
of such substances also has important health implications.
10.4.3 Composition of illicit drugs and drug tablets
No information available.
140
Part B: Selected Issues
Summary of selected issues
11. Drug-related health policies and services in prison
The profile of the typical drug-using prisoner in Ireland is single, aged between 14 and
30, male, living in the parental home, from a large and often broken family, having left
school before the legal minimum age of 16, unemployed, with his best-ever job having
been in the lowest socio-economic class. He will have a high number of criminal
convictions and a history of other family members being in prison; there is a high rate
of high rate of recidivism among these prisoners. The typical drug-using prisoner has
also experienced extreme social disadvantage, being from an area with a high
proportion of local authority housing and often with high prevalence of opiate drug use
and a high level of long-term unemployment.
The widespread availability of drugs in prison, despite supply reduction initiatives, has
been confirmed through data from prison drug-testing, and reports from the Inspector
of Prisons, an independent statutory function which has oversight for Irish prisons. A
prison survey currently under way will provide further information on drug-using
patterns and practices among prisoners, both in prison and in the community. A recent
study by the HRB on drug-related deaths post-release concluded that many of the
deaths were preventable and the findings support the need for an overdose prevention
strategy.
One of the key benchmark criteria relevant to the treatment of prisoners is equivalence
of care. This, according to the Inspector of Prisons, is the minimum legal standard
required in prison healthcare and entitles prisoners to the same care as that available
in the community.
Since the launch of the Irish Prison Service (IPS) drugs policy and strategy document,
Keeping drugs out of prisons, the provision of drug services in Irish prisons has
improved. The IPS is committed to achieving care equivalent to that available in the
community. Those presenting with problem opiate use are offered detoxification if it is
clinically indicated, or stabilisation on methadone and addiction counselling as
treatment options. The contracting-out of treatment services to addiction services
based in the community and to private consultants including pharmacists has also been
beneficial and has enhanced links between prison and community-based services.
Although there has been an improvement in the drug-related health policies and
services in Irish prisons in recent years, the effective delivery of these services and the
attainment of the goal of equivalence of care have been undermined because of severe
prison overcrowding. In such a context the therapeutic benefit of drug treatment can
become a secondary concern to the control and security priorities of the prison
environment. Equally, a lack of clarity of responsibility and coherence of delivery
hinders the provision of a seamless care service pre and post release and exposes
vulnerable people to preventable drug-related deaths.
12. Drug users with children
In 2006/7, just over 23% of all respondents to the all-Ireland general population drug
use prevalence survey who reported having ever used any illegal drug, and 4% who
reported having used any illegal drug in the last year, also reported that they had
dependent children aged 18 years or younger. Between 2003 and 2009, NDTRS data
showed that the proportion of drug users in treatment reporting that they lived with a
partner and children ranged between 10.2% and 10.8%, and the proportion reporting
that they lived alone with children ranged from 3.7% to 4.6%. A number of separate
studies, undertaken between 1992 and 2007 at two of Dublin’s maternity hospitals,
found that the prevalence of illicit drug use among pregnant women ranged between
1% and 4.57%.
141
While there has been one major empirical study of the impact of parental drug use on
children in Ireland, authors of other Irish research reports have indicated the need to
research what amount to ‘hidden populations’ of children whose parents use drugs and
to explore their particular experiences, vulnerabilities and risk profiles. These
researchers have also highlighted the need for specific policies and services targeting
these populations.
Statutory services in Ireland to ensure the welfare and protection of all children aged
under 18 years include guidelines which identify parental drug or alcohol use as a risk
factor leading to a welfare concern. In recent years delivery of these statutory services
has been found to be inconsistent and the delivery system is currently being revised
and strengthened. The need for adequate training for professionals implementing these
guidelines in situations where parents are drug users is highlighted in several Irish
research studies, in order to ensure these professionals are prepared and sufficiently
sensitive and responsive to what are often complex and always unique situations.
142
11.
Drug-related health policies and services in prison
11.1
Introduction
There are 14 institutions in the Irish prison system comprising 11 traditional ‘closed’
institutions, two open centres, which operate with minimal internal and perimeter
security, and one ‘semi-open’ facility with traditional perimeter security but minimal
internal security (the Training Unit). The majority of female prisoners are
accommodated in the purpose-built Dóchas Centre adjacent to Mountjoy prison in
Dublin and the remainder are located in a separate part of Limerick prison. Sixteenand seventeen-year-old boys are held in a separate wing of St Patricks Institution
beside Mountjoy prison.
Political responsibility for the prison system in Ireland is vested in the Minister for
Justice, Equality and Defence. The Irish Prison Service (IPS) operates as an executive
agency within the Department of Justice, Equality and Defence. It is headed by a
Director General supported by seven directors. An important source of information and
data for this selected issue are reports compiled by Office of the Inspector of Prisons.
The Office of the Inspector of Prisons is a statutory, independent office established to
carry out regular inspections of the 14 prisons and to report to the Minister for Justice,
Equality and Defence. The Inspector of Prisons has recently deliberated on the various
national and international legal obligations owed to prisoners by the state and the
various legal provisions and processes which have a bearing on the conditions of
prisoners. Two policy documents have a particular bearing on the provision of drugrelated healthcare in the Irish prison system – the IPS policy and strategy document,
Keeping drugs out of prisons, and the National Drugs Strategy (interim) 2009–2016.
Prevalence data regarding drug use and problem drug use in Irish prisons are not
routinely collected. Indirect indicators of prison drug use include drug seizures and data
obtained from prison drug tests. Data on drug-related deaths following release from
prison have also recently been compiled by the National Drug-Related Deaths Index
(NDRDI) of the Health Research Board. Information on prison drug treatment is
contained in reports of the IPS, while data on the numbers in receipt of methadone are
compiled by the Central treatment List. Replies to parliamentary questions by relevant
Ministers have also been a useful source of data for this selected issue.
11.2
Prison systems and prison populations: contextual information
There are 14 institutions in the Irish prison system consisting of 11 traditional ‘closed’
institutions, two open centres, which operate with minimal internal and perimeter
security, and one ‘semi-open’ facility with traditional perimeter security but minimal
internal security (the Training Unit). The majority of female prisoners are
accommodated in the purpose-built Dóchas Centre adjacent to Mountjoy prison in
Dublin and the remainder are located in a separate part of Limerick prison.11 Sixteenand seventeen-year-old boys are held in a separate wing of St Patricks Institution
beside Mountjoy prison. On 23 July 2011, the prison population numbered 4,478, and
of this 163 were female (Reilly, Judge Michael 2010). See Table 11.1.1 for a summary
of stated bed capacity per prison and the numbers in prison on this day.
Table 11.1.1 Bed capacity (BC) and numbers in custody (NIC) in Irish prisons, 23 July 2010
Name
Description and Location
BC
NIC
Mountjoy
Committal prison for adult male 630 728
prisoners, at North Circular
Road, Dublin 7.
Dóchas
Committal prison for female
105 140
prisoners aged 17 years and
over at North Circular Road,
Dublin 7
Limerick
Committal prison for adult male (M)
(M)
11
Source: Homepage of the IPS www.irishprisonservice.ie
143
Name
Cork
Castlerea
Cloverhill
Arbour Hill
Midlands
Portlaoise
Wheatfield
Shelton Abbey
St Patricks Institution
Loughan House
Training Unit
Description and Location
and female prisoners, at
Mulgrave Street, Limerick.
Committal prison for adult male
prisoners, at Rathmore Road,
Cork.
Committal prison for adult male
prisoners, at Harristown,
Castlerea, Co. Roscommon.
Committal prison for remand
adult male prisoners, at
Cloverhill Road, Clondalkin,
Dublin 22.
Prison for adult male prisoners,
at Arbour Hill, Dublin 7.
Prison for adult male prisoners,
at Dublin Road, Portlaoise, Co.
Laois.
Prison for adult male prisoners,
including the detention of high
security prisoners, at Dublin
Road, Portlaoise, Co. Laois
Prison for adult male prisoners,
at Cloverhill Road, Clondalkin.
An open centre for male
prisoners aged 19 years and
over, at Arklow, Co. Wicklow
An institution for male juveniles
aged 16 to 21 years, at North
Circular Road, Dublin 7.
An open centre for the
detention of male prisoners
aged 18 years and over, at
Blacklion, Co. Cavan
A semi-open place of detention
for male prisoners aged 18
years and over, at Glengarriff
Parade, Dublin 7, for industrial
training.
BC
290
(F)2
0
272
NIC
322
(F)2
3
316
351
414
431
462
148
151
591
568
359
273
470
507
110
108
217
210
160
142
117
114
Source: IPS 2011 www.irishprisons.ie
Source for BC and NIC data: (Reilly, Judge Michael 2010)
During 2010 there were a total of 17,179 committals to prison in Ireland. This
represents an 11.4% increase on the figure for 2009 (IPS Annual report 2010). With
regard to the general profile of the Irish prison population, in the absence of regularly
available data or in-depth research, information recently gathered by the Irish Penal
Reform Trust (IPRT)12 provides a basic insight13
 The rate of imprisonment in Ireland is 101 per 100,000 of population (July 2010).
 The prison population has increased by 400% since 1970.
 60% of people serving sentences for 6 months or less are poor, and are often
homeless.
 The majority of Irish prisoners have never sat a State exam and over half left school
before the age of 15.
 In 2009, 162 people were imprisoned for the non-payment of a civil debt.
 There were 673 committals under immigration law in 2009.
 228 young people aged under18 were committed to prison in 2009, including one
girl.
 There were 3,601 sentenced committals for road traffic offences in 2009,
representing 33.1% of the total, an increase of 59% on 2008.
 20.8% of sentenced committals in 2009 were for offences against property without
violence.
12
The Irish Penal Reform Trust is Ireland’s leading non-governmental organisation campaigning for penal reform and
prisoners rights.
13
http://www.iprt.ie/prison-facts-2
144











Prisoners in Ireland are 25 times more likely to come from (and return to) a
seriously deprived area.
Just under 30% of prisoners in Ireland are still ‘slopping out’, with no access to incell sanitation.
90.3% of sentenced committals in 2009 were for non-violent offences.
82.4% sentenced committals of women in 2009 were for non-violent offences.
70% of sentenced committals in 2009 were for six months or less.
In 2008, of the 520 prisoners who enrolled in the school at Mountjoy prison, 20%
could not read or write and 30% could only sign their names.
6,681 people were imprisoned for non-payment of court-ordered fines in 2010; 152
of those were for failing to pay court fines for not having a television licence.
There were seven suicides recorded in Irish prisons in 2007, and 11 in 2008.
Since 1997, more than 1,930 new spaces have been added to an increasingly
overcrowded prison system.
There are 250 'protection' prisoners being held on 23-hour lock-up (17 December
2010).
Over 70% of prisoners are unemployed on committal and a similar percentage selfreport as not having any particular trade or occupation.
With regard to the social profile of Irish drug-using prisoners, a pioneering study by
O’Mahony in Mountjoy prison in Dublin, the largest prison in the state when the study
was undertaken, found them typically to be single, aged between 14 and 30, male,
urban, with many still living in the parental home, from large and often broken families,
having left school before the legal minimum age of 16, with high levels of
unemployment, with their best-ever job being in the lowest socio-economic class, with
a high number of criminal convictions and high rates of recidivism, with a history of
family members being in prison, and a profile of extreme social disadvantage
characterised by being from areas with a high proportion of local authority housing and
often by the prevalence of opiate drug use and high levels of long term unemployment
(O'Mahony, P. 1997).
A more recent study on prison recidivism has confirmed that the general profile of the
Irish prison population remains largely unchanged (O'Donnell, Ian, et al. 2007). The
geographical distribution of prisoners released in 2004 was mapped to find out about
the community contexts from which prisoners were drawn and to which they were likely
to return. Data from the new IPS computer-based records system, Prison Records
Information System (PRIS), was used to track and map the known addresses of 5,057
prisoners (out of a possible 5,588). Although the study did not focus solely on drugrelated offenders, the findings highlighted the links between socio-economic
deprivation, problematic drug use, crime and recidivism. The study found that more
than 25% of offenders were re-incarcerated within 12 months of release and
approximately 50% within four years. The most deprived areas in the country had
145.9 prisoners per 10,000 population, compared to 6.3 in the least deprived areas.
The authors stated that ‘the magnitude of this difference is startling and demonstrates
unequivocally that it is the areas already marked by serious disadvantage that most
bear the brunt of social problems that accompany released prisoners’ (p. 4).
This study clearly highlighted the link between imprisonment, drug use and poverty: in
the most deprived areas 57.8 prisoners per 10,000 were released after serving a
sentence for a drug-related crime, compared to 1.8 in the least deprived areas. In
terms of the geographic distribution of drug-related crime, Dublin, followed by the midwest region (Clare, Limerick and North Tipperary), were likely to have higher numbers
of prisoners convicted for drug-related crimes. While the distribution of violent offenders
in Dublin was spread evenly between the suburbs and the inner city, prisoners serving
a sentence for drug offences and, to a lesser degree, for property offences were more
likely to come from the inner city than the suburbs.
145
Drug use and problem drug use in prisons and after release
Prevalence data regarding drug use and problem drug use in Irish prisons are not
routinely collected. With regard to harmful drug use among prisoners, previous studies
in Ireland have found higher prevalence rates for self-reported current and having ever
used drugs, in addition to higher prevalence rates for hepatitis B, hepatitis C and HIV,
among prisoners than in the general population (Allwright, et al. 1999) (Allwright, et al.
2000) (Long, et al. 2000) (Long, et al. 2001) (Long, et al. 2003) (Long, et al. 2004).
Other indirect indicators of prison drug use include drug seizures (see Chapter 10.3.1)
and data obtained from prison drug tests. In 2005 new Prison Rules were introduced,
dealing with all aspects of prison life, including accommodation, visiting rights,
discipline, health and education (Department of Justice Equality and Law Reform
2005). These rules provided for the introduction of compulsory or mandatory drug
testing (MDT) of prisoners. Section 28 (5) (a) states: ‘In the interest of good order,
safety, health and security and in accordance with directions set down by the minister,
a prisoner … shall, for the purpose of detecting the presence or use of an intoxicating
liquor or any controlled drug … provide all or any of the following samples, namely –
urine, saliva, oral buccal transudate, hair.’
Information on drug testing in prisons in 2009 was obtained from the IPS by the HRB.
These data indicate that more than 28,000 voluntary tests were carried out to monitor
drug use and responses to treatment in 2009. These tests included those carried out
on some committals (new entries) as well as those carried out on existing inmates. It
may be assumed therefore that some of the positive test results relate to drugs or
alcohol consumed outside the prison.
Excluding methadone, between one-tenth and two-fifths of those screened tested
positive for at least one drug. The common metabolites detected indicate use of
cannabis, benzodiazepines and opiates (see National Report 2010 section 4.4) (Irish
Focal Point 2010).
Another source of information on prison drug use is contained in reports prepared by
the Inspector of Prisons.14 Following a number of reviews of prisons throughout the
Irish prison estate, the Inspector of Prisons recently concluded that ‘the overall level of
drug abuse in our prisons is very high’ (Reilly, M 2009) (para. 10.3) (see NR 2010
Section 9.5) (Irish Focal Point 2010). In a further report, The Irish prison population –
an examination of duties and obligations owed to prisoners, he identified a range of
issues associated with drug use throughout the prison estate (Reilly, Judge Michael
2010). These include the following:




Castlerea: ‘Drugs are not a major cause for concern…I have been informed that a
methadone maintenance programme is to be introduced in the coming months.’
(para 7.13)
Cloverhill: ‘The prevalence of drugs is not a major cause for concern in Cloverhill
Prison but as the prison population is transient problems may arise that may not be
found in the committal prisons.’ (para 8.11)
Cork: ‘Drugs are a problem in the prison but I have been informed that because of
the type of nets over two yards this is not a source of supply.’ (para 9.9)
Dochas: ‘There is now no dedicated drug-free area in the prison due to
overcrowding…because of overcrowding prisoners with drug problems are
accommodated in houses (that were formerly drug free)…Drugs are a serious
problem…There are no nets over the yards. The increase in population has also
intensified the demand for illicit drugs…During a number of my latter visits I
observed prisoners obviously under the influence of some form of drugs.’ (para
10.6)
14
The Office of the Inspector of Prisons is a statutory, independent office established under the Prisons Act 2007. The
key role assigned to the Inspector is to carry out regular inspections of the 14 prisons in the State and to present his
report(s) on each institution inspected as well as an Annual Report to the Minister for Justice and Law Reform.
146








Limerick: ‘Drugs are a major problem in the prison. I and my staff have observed
many prisoners obviously under the influence of drugs’ (para 11.11), and in the
female prison, ‘Drugs are a very serious problem. On numerous occasions my staff
and I have observed prisoners obviously under the influence of drugs.’ (para 11.29)
Midlands: ‘Drugs are not a major cause for concern in the prison.’ (para 13.5)
Mountjoy: ‘Drugs are a major problem in the prison. I have been informed that new
nets are to be erected over the yards which should curtail the amount of
drugs…that reach prisoners by that route. It is not unreasonable to speculate,
because of the number and types of seizures, that drugs and contraband enter the
prison by other routes.’ (para 14.16)
Portlaoise: ‘Drugs are not an undue problem in the prison.’ (para 15.8)
Shelton Abbey Open Centre: ‘Drugs are not a problem in the prison.’ (para 16.8)
St Patrick’s Institution: ‘Drugs are a problem…One source of supply is over the
perimeter wall into the yards.’ (para 17.6)
The Training Unit: ‘Drugs are not a problem in the prison.’ (para 18.10)
Wheatfield: ‘Drugs are not a major problem in Wheatfield Prison.’ (para 19.8)
Drug-related deaths upon release from prison
International research has found an increased risk of mortality among prisoners within
the days and weeks following their release from prison (Binswanger, et al. 2007). Many
of these deaths are drug-related and the increased mortality risk is thought to be
caused by the altered tolerance to drugs which an individual may develop while in
prison (Jones, et al. 2002) (Seymour, et al. 2000). A recently published paper based on
data from the National Drug-Related Deaths Index (NDRDI) for the years 1998–2005
examined the relationship between date of release from prison and drug-related death
(Lyons, Suzi, et al. 2010). This was the first study of its kind in Ireland.
Profile of cases examined
Between 1998 and 2005, 2,442 drug-related deaths were recorded on the NDRDI. One
hundred and thirty of the individuals who died had a documented history of
imprisonment. Of the 130 individuals, 105 were not in prison at the time of death. Of
these 105 individuals:
 the majority (93, 88.6%) were male;
 most (69, 65.7%) were aged between 20 and 29 years (median age 29 years);
 the majority (88, 83.8%) were unemployed;
 21 (20.0%) were living in unstable accommodation, and 10 (9.5%) were homeless;
 64 (61.0%) had a history of injecting, and 36 (34.3%) were injecting at the time of
death; and
 11 (10.5%) had a blood-borne viral infection recorded in their history, of whom five
were co-infected with two or more viruses.
Time between release from prison and death
Of the 105 individuals, 89 had a known date of release (Figure 11.1.1). Of these, nine
(10.1%) died on day one or day two, and 16 (18.0%) died between day three and day
seven. Almost half (42, 47.2%) of the 89 deaths occurred within the first month of
release.
147
25
22
20
Number
18
15
16
12
10
9
7
5
5
0
Figure 11.1.1 Relationship between date of release from prison and drug-related death (n=89),
NDRDI 1998–2005
Deaths by poisoning within the first month of release
Of the 42 deaths within the first month of release, 38 were due to poisoning, and 18 of
those who died were injecting drugs at the time of their death. Of the 14 deaths
involving a single drug, 11 involved an opiate, mainly heroin and/or methadone (Table
11.1.2). Of the 24 deaths involving polysubstances, 23 involved an opiate (in addition
to one or more other substances).
Table 11.1.2 Substances involved in deaths by poisoning within the first month of release from
prison (n=38), NDRDI 1998–2005
Substance
n (%)*
Heroin
19 (50.0)
Methadone
18 (47.4)
Benzodiazepines
11 (28.9)
Antidepressants
Stimulants
Other
‡
6 (15.8)
†
7 (18.4)
11 (28.9)
* The sum of percentages in this column exceeds 100% as most deaths involved more than one substance.
† Includes cocaine and methamphetamine.
‡ Includes non-benzodiazepine sedatives, unspecified opiates, analgesics containing an opiate compound, anti-psychotics, non-opiate
analgesics, alcohol, solvents, cardiac and all other types of medication, including over-the-counter products.
The findings of this study are consistent with those of international studies in this area.
The number of cases reported in this study is likely to be underestimated, as history of
imprisonment is not routinely recorded in the NDRDI data sources. The study highlights
the need for education and awareness among prisoners and their families and friends
about the risk of overdose in the days and weeks following release. Many of these
deaths are preventable and the findings of the study support the need for an overdose
prevention strategy.
11.3
Organisation of prison health policies and service delivery
Prison health
Political responsibility for the prison system in Ireland is vested in the Minister for
Justice and Equality. The IPS operates as an executive agency within the Department
of Justice and Equality. It is headed by a Director General supported by seven
directors. A non-executive Prisons Authority Interim Board provides advice guidance in
the management of the prison system.
148
The Inspector of Prisons has recently deliberated upon the various national and
international legal obligations owed to prisoners by the state and the various legal
provisions and processes which have a bearing on the conditions of prisoners (Reilly,
Judge Michael 2010). The Inspector states that:
As a country our obligations towards our prisoners can be found in our
Constitution, our laws, our jurisprudence, our prison rules and in the standards
that I published. Our international obligations can be found in the many
international instruments to which we are a party, the jurisprudence of the
European Court of Human Rights [ECHR], the European and International rules
that refer to prisoners and the reports of the European Committee for the
Prevention of Torture and Inhuman or Degrading Treatment or Punishment (the
CPT). (para 1.9)
In supporting the right of Irish prisoners to adequate health care, the Inspector cites a
number of further authorities including the World Health Organizations’ Constitution of
1946; the Universal Declaration of Human Rights 1948 (para 2.1); article 12(1) of the
International Covenant on Economic, Social and Cultural Rights, to which Ireland is a
signatory; Articles 40 to 44 of the Irish Constitution which, although not specifically
referring to a right to health have, over time, been interpreted as implying a ‘right to
bodily integrity’, a right not to have one’s health ‘exposed to risk or danger’ and the
right ‘not to be subjected to inhuman or degrading treatment’ (para 2.6). As a result of
the incorporation of the ECHR into Irish law, prisoners can now take legal actions in
domestic courts or they can apply for redress to the ECHR when all domestic legal
remedies have been exhausted. The Inspector points out that ‘in special and
extraordinary circumstances and where it can be demonstrated that a state has failed
to improve systemic or structural conditions or problems an application can be made
directly to the European Court of Human Rights without exhausting domestic
remedies.’ (para 1.2)
The three general headings under which the state owes obligations to prisoners are (1)
appropriate accommodation, (2) adequate services and regimes, and (3) prisoner
safety. According to the Inspector, and for the purpose of this select issue, ‘services
and regimes’ include such matters as ‘education, structured vocational work training,
recreation, exercise…health, welfare, diet…addiction and psychology services’ (para
3.5). With regard to the standards required, the Inspector states that, ‘The United
Nations Minimum Rules for the Treatment of Prisoners, the European Prison Rules and
the observations of the CPT do not have statutory authority but must be considered
persuasive.’ (para 3.3) However, with regard to the status of the Irish Prison Rules, the
Inspector concurs with a previous court decision by O’Higgins Chief Justice in the case
of State (Walsh and McGowan) – v – Governor of Mountjoy,15 when he stated that
‘having been made under the authority of the various Prison Acts, they have statutory
effect and must be so regarded’ (Reilly, Judge Michael 2010): para 3.4).
The Inspector of Prisons has set out the various provisions under the instruments
outlined above that he believes are relevant when determining the level and
appropriateness of services and regimes that should be provided in Irish prisons. In a
further report published in April 2011, Guidance on physical healthcare in a prison
context, the Inspector sets out for the IPS ‘the guidance available from all relevant
sources which, if accepted, should lead to best practice in the provision of healthcare in
our prisons’(Reilly, Judge Michael 2011) (para 1.3). He notes that the guidance
provided is ‘relevant not only to the IPS and local management of prisons but also to all
those who contribute to the healthcare of prisoners be they working within the Irish
prison system or as contractors to the system.’ (para 1.5)
In addition to these general instruments, the Inspector of Prisons lists instruments
specifically recognising a prisoner’s right to health, including the Council of Europe’s
15
Unreported, High Court, 12 December 1975.
149
Recommendation (98)7 concerning the ethical and organisational aspects of
healthcare in prison, Principle 9 of the Basic Principles for the treatment of prisoners,
and Principle 1 of the Principles of Medical Ethics relevant to the Role of Health
Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against
Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (para 3.4).
With regard to the last, the European Committee for the Prevention of Torture and
Inhuman or Degrading Treatment or Punishment (CPT) includes the provision of
healthcare in prisons within its mandate when observing and making recommendations
on the obligations of signatory states, including Ireland. In explaining this position, the
CPT has stated: ‘…an inadequate level of healthcare can lead rapidly to situations
falling within the scope of the term “inhuman and degrading treatment”…regardless of
the difficulties faced at any given time, the act of depriving a person of his liberty
always entails a duty of care which calls for effective methods of prevention, screening,
and treatment’ (quoted in (Reilly, Judge Michael 2011): para 3.7).16 In a recent visit to
Ireland, the CPT was highly critical of aspects of the drug treatment regime in the Irish
prison system (Committee against Torture 2011).
One of the key benchmark criteria relevant to the treatment of prisoners is equivalence
of care. This, according to the Inspector of Prisons, ‘is the minimum required in a prison
healthcare context and entitles prisoners to the same care as that available in the
community.’ (Reilly, Judge Michael 2011) (para 3.11). The stated aim of the Irish Prison
Service is ‘to deliver a quality of healthcare reflective of that available to those holding
medical cards in the wider community, taking into consideration the constraints that
custody imposes’ (Annual report 2010, p28).The observations of the CPT and the
Inspector of Prisons in relation to compliance by the IPS with equivalence of care
criteria will be discussed below.
Drug-related health policies targeting prisoners
Two policy documents have a particular bearing on the provision of drug-related
healthcare in the Irish prison system – the IPS policy and strategy document, Keeping
drugs out of prisons, and the National Drugs Strategy (interim) 2009–2016 (NDS).
In May 2006 the Minister for Justice launched Keeping drugs out of prisons: drug policy
and strategy (Irish Prison Service 2006a). This sets out the steps required to tackle the
supply of drugs into prisons, to provide adequate treatment services to those who are
addicted to drugs, and to ensure that developments in the prisons are linked to those in
the community. The IPS, in partnership with statutory and voluntary agencies, provides
programmes to assist in the areas of prevention, treatment, rehabilitation and aftercare,
both to address the harmful effects of substance use and to prevent the spread of HIV,
hepatitis B and C and other infections. Phase 1 of this policy involved putting in place
the necessary staffing levels to provide the required services to prisoners. Phase 2
sought to provide prisoners with access to a range of drug treatment options
‘consistent with the objective of achieving a standard of care which is equivalent to that
available in the community’ (Department of Community Rural and Gaeltacht Affairs
2009) (para 4.46). The specific measures which have been adopted as part of the
strategy and the progress made in relation to them are described in Section 11.3
below.
The following actions in the NDS relate to treatment in prisons (Department of
Community Rural and Gaeltacht Affairs 2009):

16
Treatment and rehabilitation (Action 43) – Continue the expansion of treatment,
rehabilitation and other health and social services in prisons and develop an agreed
protocol for the seamless provision of treatment services as a person moves
between prison (including prisoners on remand) and the community; and
The CPT quote is derived from CPT 3rd General Report [CPT/Inf(93)12] at para 30.
150

Research/information (Action 55) – research prevalence patterns of problem
substance use among prisoners.
The Steering Group that drafted the NDS also explains that ‘a small expert group has
been convened to consider the issues of providing needle exchange in prisons’ (para.
4.48). With regard to the risk of overdose or relapse immediately following release from
custody, the Steering Group states that there is a need for ‘an effective and coordinated interagency approach to ensure the seamless transition from prison back into
the community. This requires the availability of, and timely access to, a range of
supports including suitable accommodation, treatment/counselling services,
training/education/ employment options and personal supports’ (para. 4.49). However,
the Steering Group continues that, ‘clarity is required around who will deliver these
services, including planned release and post-release arrangements’ (para 4.49).
In 2005, the mid-term review of the previous National Drugs Strategy 2001–2008
recommended that rehabilitation be adopted as a fifth pillar of the strategy (Department
of Community Rural and Gaeltacht Affairs 2005). Arising from this recommendation,
the HSE appointed an expert working group in 2006 to describe residential treatment
services for problem drug and alcohol users in Ireland, to calculate their capacity and to
estimate future requirements (O'Gorman and Corrigan 2008). In relation to the issue of
throughcare upon release from prison, this expert working group recommended the
‘provision of step-down or halfway-house accommodation for newly released prisoners
who have been detoxified or who have started rehabilitation programmes…not least
because of the vulnerability of such individuals to relapse and overdose’ (p. 5).
11.4
Provision of drug-related health services in prison (please provide
methodological information: information sources, method of data collection and
analysis, limitations)
Prevention, treatment, rehabilitation, harm reduction
In line with Keeping drugs out of prisons (Irish Prison Service 2006a), described in
Section 11.2 above, new services and programmes for addicted prisoners were
developed in 2006. These are delivered by the IPS in partnership with the HSE and
contracted private services. The 2009 IPS annual report states that the provision of
drug treatment services continues to be one of the ‘biggest and most resource
intensive challenges for healthcare in the prisons setting’ (Irish Prison Service 2010) (p.
41). The report also describes the various social and health programmes available to
prisoners. Educational programmes include basic education, i.e. literacy and
numeracy, creative arts, information technology, woodwork, general subjects including
languages and the arts, life skills courses and physical education courses. Vocational
training courses are also provided including printing, computers, metalwork,
construction, catering etc.
With regard to drug treatment services, the 2009 annual report states that ‘the Irish
Prison Service...in the national context of drug treatment provision, has cared for over
20% of the total numbers on methadone nationally’ (p. 41). Those who present with a
history of problem opiate use are offered detoxification if it is clinically indicated, or
stabilisation on methadone and addiction counselling as treatment options. The
Medical Unit in Mountjoy prison has spaces allocated for a dedicated drug
detoxification programme. This programme is available to any prisoner who meets the
qualifying criteria, subject to assessment. Each multi-disciplinary programme lasts six
weeks and the programme’s capacity is nine prisoners. The programme involves both
prison-based staff and external agencies and is aimed at assisting prisoners who have
indicated a desire to move from either a situation of current drug use or existing
substitution programme to drug-free status.
As a matter of policy, those who are already on methadone when committed can
continue to receive this treatment for the duration of their sentence. Prisoners who on
committal are engaged in a methadone substitution programme in the community will,
151
in the main, have their methadone substitution treatment continued while in custody.
Methadone maintenance is available in eight of the 14 places of detention, which
accommodate over 80% of the prison population (IPS Annual report 2010, p29) (Irish
Prison Service 2011).
According to the IPS, ‘addiction counselling services are available in all prisons and
places of detention where prisoners require such a service. … The service offers
structured assessments and evidence-based counselling interventions with clearly
defined treatment plans and goals’ (Irish Prison Service 2010) (p. 41). Counselling is
available to prisoners who have a history of drug use including opiates, cocaine,
ecstasy, amphetamines, LSD, anxiolitics, hypnotics, alcohol, cannabis and other illicit
and licit drugs. The Psychology Service in Mountjoy prison has, according to the IPS
annual report for 2010, ‘adapted a manualised motivational programme for drug users
to a prison context. This programme is based on the trans-theoretical model of
behaviour change and principles of motivational and cognitive behavioural psychology’
(Irish Prison Service 2011) p. 25.
Primary care is the model of care through which healthcare is delivered in the prison
system. A number of contracted private services assist the IPS and HSE in the
provision of drug treatment services. The service is provided by a mix of part-time and
full-time doctors and nursing staff. Nurses first began working in the IPS in 1999
(Nursing and Midwifery Planning and Development Unit & Irish Prison Service 2009).
Addiction counselling services have been provided to the IPS by Merchants Quay
Ireland (MQI) since 2007. A voluntary organisation providing services to vulnerable
people including drug users, in 2008 MQI completed the implementation of a national
prison-based addiction counselling service to 13 prisons. In excess of 1,300
counselling hours were provided in 2010, and the 23 counsellors each carried an
average caseload of 550 prisoners (Merchants Quay Ireland 2011). A tender for the
continuation of this service was finalised in 2010 with MQI securing the contract for a
further three years (Irish Prison Service 2011).
Professional pharmacy services are in place in all prisons. According to the IPS, ‘the
introduction of pharmacy services also supports more effective throughcare, as each
prisoner’s dispensed medicines are now sent with him/her on transfer to another
prison’ and can also be given to him/her on full or temporary release until the prisoner
can engage with the community healthcare services’ (Irish Prison Service 2010) (p.
40). Since May 2010, according to the IPS, ‘Pharmacists are now responsible for all
aspects of drug treatment (mainly methadone) dispensing, administration, recording,
ordering, storage etc’, in Mountjoy, Dochas womens prison, Midlands and Portlaoise
prisons (Irish Prison Service 2011). A number of specialist tertiary services provide inreach medical care to the prison population. Service level agreements are in place with
the HSE, for example, to provide consultant-led addiction services to Cloverhill,
Wheatfield and Mountjoy prisons. A consultant-led infectious diseases service has also
been contracted from St James Hospital in Dublin to provide treatment to prisoners
who suffer from infectious diseases including hepatitis C and HIV. According to the
IPS, ‘the development of this service has demonstrably decreased the number of
prisoners transferred to St James Hospital Guide Clinic for screening and treatment’
(Irish Prison Service 2010) (p. 40).Table 11.4.1 shows the treatment options available
by prison in September 2010.
Table 11.4.1: Treatment options available by prison, September 2010
Institution
Treatment types
Mountjoy,
Dóchas,
St. Patrick’s,
Cloverhill,
Wheatfield,
Portlaoise, Midlands
Methadone/detox, stabilisation and maintenance
Full range of counselling services
Provided by
IPS,
HSE,
MQI
152
Institution
Treatment types
Provided by
Loughan House,
Shelton Abbey,
Castlerea
Addiction Counselling Services
Focused on Alcohol /Cannabis
Abstinence driven
IPS,
MQI
Cork
Alcohol /Cannabis
Abstinence driven — physical space a barrier to
service provision
IPS,
MQI,
Local Drugs Task
Force
Limerick
2 models of counselling in operation; abstinence
based and a harm reduction model
Methadone Substitution treatment is determined
following clinical evaluation
IPS,
MQI,
ALJEF*
Training Unit
Counselling
IPS,
MQI,
Coolmine**
Source: (Ahern, Dermot 2010, 29 September)
* ALJEF Addiction Services in Limerick www.aljef.org
** Coolmine therapeutic community www.coolmine.ie
The National Drug Treatment Reporting System (NDTRS) records information on some
drug treatment in prison (see Standard Table 24 for latest data). These data show that
there were 794 individuals treated for problem drug use in Irish prisons in 2009 (751
male, 42 female). For the purpose of the NDTRS, treatment is broadly defined as ‘any
activity which aims to ameliorate the psychological, medical or social state of
individuals who seek help for their substance misuse problems’ (Bellerose, et al. 2010).
However, most of the treatment data for prisons supplied to the NDTRS for 2009 is in
relation to drug counselling.
Another source of data is the Central Treatment List (CTL). All prisoners who receive
methadone treatment in prison are recorded on the CTL database. As explained
above, methadone maintenance is available in 8 of the 14 places of detention,
accounting for over 75% of the prison population. The number of prisoners on
methadone maintenance treatment increased by 20% between 2008 and 2009 (Irish
Prison Service 2010). There was a 10% increase in the number of people new to
treatment. Over 20% of those on the CTL in 2009 were treated within the IPS, and 31%
of all new entrants on the CTL in 2009 were treated within the IPS. On 31 December
2010, the CTL reported that there were 539 people attending methadone treatment in
prison in Ireland (personal communication, Suzi Lyons, HRB, July 2011). Of these, 33
were female. Table 11.4.2 shows the numbers in receipt of methadone substitution
treatment by prison.
Table 11.4.2: Number of cases attending methadone treatment in prison, 31 December 2010
Prison
Number receiving methadone
Cloverhill
84
Wheatfield
97
Mountjoy male
206
Mountjoy medical unit
16
Dochas centre (female)
30
St Patrick’s
0
Midlands
56
Portlaoise
25
Limerick
22
Total
539
Source: Central Treatment List, unpublished data, July 2011
In response to a parliamentary question, in October 2010 the former Minister for
Justice, Equality and Law Reform stated that there were 34 prisoners in the prison
system on waiting lists for drug treatment programmes at that time. He further stated
that ‘No prisoner has been on the waiting list for more than three months (Ahern,
Dermot 2010, 07 October).
153
11.5
Service quality
Practical guidelines and standards of drug-related health services have been outlined
in a comprehensive drug treatment clinical policy document, Drug treatment clinical
policy (Irish Prison Service 2008). The policy document covers:
 clinical interdisciplinary care planning,
 methadone treatment guidelines,
 assessment – treatment plans and treatment goals (induction, maintenance and
detoxification),
 criteria for treatment priority,
 use of methadone – ordering and dispensing, and
 administration and recording of methadone.
The document details the processes necessary for methadone treatment, whether a
prisoner is already on methadone on admission or is to be initiated into treatment in
prison, and for planned release of a prisoner on methadone. Issues around bloodborne viruses, including testing, clinical management and immunisation, are also
addressed in the policy.
The document states that the misuse of benzodiazepines is an endemic problem in the
Irish prison population and recommends policies and guidelines around assessment of
dependence, prescribing and detoxification. The Lofexidine detoxification and alcohol
withdrawal guidelines have been modified from The Maudsley protocols. Guidelines
for the use of Naltrexone, as part of an overall programme of addiction treatment, along
with psycho-social support, are outlined in the document. The guidelines state that
Naltrexone should only be prescribed by a medically-qualified person experienced in its
use. The use of injectable Naltrexone for reversing accidental opiate overdose is not
covered.
The document states that an interdisciplinary team will provide treatment for problem
cocaine use on an individual basis. There is a range of treatments available including
counselling and cognitive behavioural therapy, along with appropriate referrals to
medical or psychiatric services as necessary. It is the policy of the IPS, in accordance
with the community standard, to develop a dual diagnosis service for those patients
with addiction problems and mental health problems. See Chapter 12.3.2 for details of
guidelines on treatment of pregnant women in prison.
The IPS document Health Care Standards (Irish Prison Service 2009) provides further
guidance on the general provision of healthcare in Irish prisons. These standards have
been developed by a multidisciplinary group representing the various health-related
interests involved in prisoner health care. The standards recognise the need not only to
define the services to be provided but also to measure the effectiveness of such
services. In relation to drug treatment services, healthcare standard 9 states:
 to provide clinical services for the assessment, treatment, and care of substance
misusers comparable to those available in the community, and which are
appropriate to the prison setting, and
 all methadone treatment delivered to prisoners will be based on IPS Methadone
Guidelines as derived from the European Methadone Guidelines.
A recent study of the nursing service in the Irish prison system gives an insight into the
challenges in implementing the guidelines. The report set out 16 goals for the future
development of prison nursing and healthcare in Ireland, each with its own set of
recommendations. The authors stated that many of the associated recommendations
did not require additional resources or funding, but restructuring and integration of
existing services and resources and effective collaboration at all levels (Nursing and
Midwifery Planning and Development Unit & Irish Prison Service 2009). For a detailed
account of the findings, see National Report 2010 Chapter 5.3.2 (Irish Focal Point
2010).
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11.6
Discussion, methodological limitations and information gaps
Equivalence of care
Equivalence of care is both a legal requirement and a clear policy goal of the IPS while
the NDS aims to ensure the seamless provision of treatment services as a person
moves between prison (including prisoners on remand) and the community. In its
annual report for 2010, the Irish Prison Service, although re-stating its commitment to
equivalence of care provision, has stated that a challenge to this objective ‘is that
prisoners have been identified, in health strategy documents, as having significant
health deficits relative to the “average” health status of the general population and as
such should be considered a “special needs2 category’ (Irish Prison Service 2011).
Notwithstanding this argument however, and although the provision of prison-based
drug services has improved, questions have recently been raised generally about the
nature and therapeutic benefit to the prisoner of the treatment provided, particularly in
relation to methadone substitution treatment.
A study by Carlin in Ireland's main committal prison, Mountjoy, used semi-structured
interviews and a focus group to explore the perceptions of staff and prisoners towards
methadone maintenance within the prison (Carlin 2005). The research subjects were
generally positive in their assessment of Mountjoy's methadone programme. Prisoners
perceived it as leading to an improvement in their relationships with their families, while
staff viewed it as facilitating a more stable and safer working environment. However,
although prisoners' use of heroin had reportedly declined since the advent of the
methadone maintenance programme, their use of other drugs had not.
There were negative views expressed by both groups about the manner in which
methadone is dispensed within the prison, and also because methadone was viewed
as being as addictive as heroin. Five different perceived purposes for using methadone
maintenance were identified: (1) to ensure continuity of harm reduction policies from
the community, (2) to reduce the supply of heroin in the prison, (3) to prevent needle
sharing and the spread of blood-borne infections, (4) to treat heroin addiction, and (5)
to control prisoners and maintain order and discipline within the prison. The study
found that there was a widely held perception that this last, latent function of
methadone maintenance could be seen as of greater importance than the more
conventional harm-reduction functions that were also identified: ‘In the majority of
interviews, prison staff described the methadone maintenance programme in terms of
keeping the prison and prisoners calm, making the prisoners less confrontational and
as a means of ensuring the prison ran smoothly’ (p. 413). The author also concluded
that the findings indicated that there were ‘operational difficulties in dispensing
methadone in a prison setting and that the therapeutic intent of the methadone
programme fitted uneasily into the custodial milieu’ (p. 413).
While it may be argued that matters have improved since Carlin’s study, which was
conducted in 2003, a more recent study by the Council of Europe’s Committee for the
Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) has
raised similar issues (European Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment 2011b). The CPT considered the provision of
prison drug treatment within the context of overcrowding, widespread drug availability,
the existence of feuding gangs, and ‘high rates of inter-prisoner violence in Mountjoy
prison’. The CPT observed that drug misuse remained a ‘major challenge’ in all
prisons visited, and that ‘management and health-care staff in most prisons visited
acknowledged both the rising numbers of prisoners with a substance abuse problem
and the widespread availability of drugs’ (p. 41). The CPT acknowledged that, since its
visit in October 2006, further investment had been made to implement the IPS drugs
strategy through initiatives such as the provision of detoxification, methadone
maintenance, education programmes, addiction counselling and drug therapy
programmes. However, the CPT stated that it had ‘serious concerns over the manner
in which methadone prescribing is carried out in Cork, Midlands and Mountjoy Prisons’
(p. 41).
155
Methadone, according to the CPT, should only be prescribed as part of a
comprehensive drug treatment programme that includes engagement with ‘addiction
counsellors, addiction nurses and as required an addiction psychiatrist’ (p. 42).
Furthermore, it stated: ‘The dose of methadone prescribed as maintenance should be
that required to stabilise a prisoner’s drug use to the extent that the inmate injects or
uses opiates less frequently and remains in contact with prison addiction services’ (p.
42). These practices were not observed at either the Midlands or Mountjoy prisons,
where, according to the CPT, there were a number of serious shortcomings. Prisoners
who were on a methadone prescription at the time of admission ‘often merely had the
dose continued and were not required to engage with the addictions counsellor …
many of the methadone prescriptions were illegible … there was a lack of medical
review of the prescription … there was no reference to the frequency of drug use,
including injecting, or to the nature of illicit drugs consumed; for example, monitoring
through regular analysis of urine’ (p. 42). At the Midlands prison, ‘urinalysis results
were not annotated in prisoners’ medical records; apparently, they were not even kept
at the prison’ (p. 42).
A further concern related to the prescription of methadone as a detoxification agent
either upon admission to prison or when an inmate identified him/herself as having an
illicit drug use problem. The absence of any assessment as to whether a prisoner was
likely to suffer from drug withdrawal subsequent to admission and the practice of
placing a prisoner who gave a history of drug use on a three-week methadone
detoxification programme were also highlighted in the report. Given that there was no
routine follow-up of withdrawal or other symptoms and no assessment as to whether
prisoners were continuing their illicit drug use on top of the prescribed methadone
detoxification, the CPT concluded that ‘for a number of prisoners in receipt of a
methadone detoxification prescription it could be stated that this was simply “free
petrol” ’ (p. 42). The CPT also found that, overall, medical records were found to be
incomplete or lacking in detail, with prisoners not receiving medical examination on
admission at Cork or Mountjoy prisons.
The CPT concluded its report with a list of recommendations, comments and requests
for information, including the following:
 all prisoners admitted while on a methadone maintenance programme in the
community to be able to continue such maintenance within prison as part of a
comprehensive drug treatment programme;
 prisoners undergoing drug withdrawal to be provided with the necessary support to
alleviate their suffering and not to be placed in a cell without integral sanitation; and
 steps to be taken to remedy the deficiencies related to the prescription of
methadone.
The Irish government has responded to the CPT report (European Committee for the
Prevention of Torture and Inhuman or Degrading Treatment or Punishment 2011a). In
relation to a recommendation that the IPS review the treatment of all prisoners at Cork,
Midlands and Mountjoy prisons receiving medication (with priority given to those
receiving methadone), the Irish government has stated that the IPS has commissioned
a number of independent reviews of a number of prisons, including ‘a review of primary
care at Midlands, Cork and Mountjoy prisons, a review of prescribing practice at
Midlands prison and a review of drug treatment services at Midlands, Cork and
Mountjoy prisons’ (p. 45). In response to criticism made by the CPT in relation to the
inadequate maintenance of medical records, the Irish government responded,
‘Subsequent to the CPT visit, the Director General [of the IPS] informed all prison
doctors of the critical importance of recording their findings following a consultation and
that the standard of medical notation must be clear, comprehensive and outline the
treatment and follow up care for each patient’ (p. 48).
Barry and colleagues, following an independent assessment of primary health care
provision in 11 out of the 14 prisons in Ireland, have also raised issues with
implications for equivalence of care provision (Barry, Joseph , et al. 2010). Using a
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checklist based on the Competence Assurance Exercise in General Practice, which
includes items such as state of premises, equipment, contracted hours, time allocation
and support staff, the report found that the medical facilities in six prisons were
unsuitable (many had been built in the 19th century) but refurbishment was planned for
some of them. In general, the standard of medical equipment was not at the same
level generally available in Irish general practice outside the prisons. Furthermore, the
authors observed there was no international benchmark for the type, quality or quantity
of essential medical equipment for prison medical facilities. The number of patients a
doctor saw per hour varied between 3.7 and 18.7, depending on the facility. Much of
this time was taken up with committals and transfers of prisoners. Seven of the eleven
prisons assessed were providing methadone maintenance treatment. Finding that most
medical facilities did not have a medical secretary, the authors stated that medical
secretaries would increase the efficiency of the medical units. They suggested that the
IPS should consider adopting the UK strategy, whereby the Department of Health has
responsibility for health care in the UK prison system, and proposed the HSE take
responsibility for delivering health care in the IPS. In its Annual Report for 2010, the
IPS (Irish Prison Service 2011) states that following concerns raised by the CPT and by
Barry and colleagues, all relevant reviews have now been completed and that the
implementation of recommendations arising from these reviews will require
‘considerable work’ and, ‘in some instances…the availability of resources’ (p 31). A
working group has been established to bring forward the implementation of the various
recommendations made.
It is also questionable whether the principle of equivalence of care can be effectively
delivered in overcrowded prisons (see Table 11.1.1). For example, the provision of
drug-free areas is directly undermined by prison overcrowding. In a joint report to the
first periodic review of Ireland under the United Nations convention against torture and
other cruel, inhuman or degrading treatment or punishment, the Irish Council for Civil
Liberties and the Irish Penal Reform Trust have highlighted the issue of overcrowding
in Irish prisons and how this has a detrimental impact on the provision of appropriate
medical care (Irish Council for Civil Liberties and Irish Penal Reform Trust 2011). The
joint submission recommends that:
 The doctor to patient ratio in the prison system should be reduced to ensure a
proper standard of care and the maintenance of adequate medical records.
 An annual report should be published on the state of medical services in the IPS.
 Drug-free units should be established across the prison estate and the state should
ensure that non-drug using prisoners are not accommodated with known drugusers as, they claim, is currently the case.
 A structured approach to reducing and eventually stopping prisoners’ dependency
on drugs must be developed.
Similar observations and recommendations about prison policy were made by Irish
non-governmental organisation Drug Policy Action Group ((O'Mahony 2008). Having
reviewed the historical background and current issues under the five pillars of the NDS,
the author concluded:
 There is an urgent need for properly designed and resourced custodial drugs
treatment centres, where useful, abstinence-oriented programmes, such as
therapeutic communities and cognitive behavioural therapies, could be provided for
suitable prisoners.
 Rehabilitation should be tailored to the individual needs and potential for personal
growth of prisoners, who very frequently come from a background of multiple
disadvantage and who have often failed disastrously in the normal education
system. A rehabilitative approach entails a strong focus on education, training and
the purposeful occupation of prisoners. This means that all new prisons should be
built at least to the standard of the Dóchas Centre Women’s Prison, exploiting
modern technology and exemplifying positive advances in architectural design.17
17
These proposals were written at a time when there was no overcrowding in the Dóchas Centre.
157


In order to achieve a more rational, effective and rehabilitative prison system, it is
essential to adjust current sentencing policy and reduce the number of minor, nonviolent, drug-using offenders sent to prison for short terms. The use of the Drugs
Court, mandatory drugs treatment outside the prison system and non-custodial
sanctions should be greatly expanded.
A more coherent drugs policy for prisons would put less emphasis on supply control
and far more emphasis on the reduction of the many different types of harm caused
to prisoners by the current drugs culture in prisons. A more coherent policy would
place far more stress on abstinence-based treatments than on methadone
substitution. A more coherent policy would recognise that improving prison
conditions and providing an environment conducive to the general rehabilitation of
offenders are absolutely essential to tackling the prison drugs problem.
Drug-related deaths, continuity of care and reintegration of drug users after
release from prison
The issue of continuity of care is related to the issue of equivalence of care. The
incidence of preventable drug-related deaths upon release from prison (Lyons, Suzi, et
al. 2010) and the high rates of recidivism associated with problematic drug users
(O'Donnell, Ian, et al. 2007) highlight the importance of providing what Action 43 of the
NDS describes as ‘the seamless provision of treatment services as a person moves
between prison (including prisoners on remand) and the community’ (Department of
Community Rural and Gaeltacht Affairs 2009)(p. 101). A number of studies have
identified the challenges in this respect.
Pugh and Comiskey evaluated the seven-week abstinence-based drug treatment
programme at Mountjoy prison in Dublin (Pugh and Comiskey 2006). Seventy-nine
clients were interviewed at two stages: stage I, prior to the treatment programme; stage
II, immediately after the treatment programme. A selected group of 20 clients were
followed up and interviewed at stage III, up to 24 months after the treatment
programme. This last sample consisted of eight prisoners who had re-offended and
returned to prison, three who were still serving their original sentence and nine who
were out of prison. These 20 also participated in a more detailed quantitative and
qualitative survey.
An 82% follow-up rate was achieved on the original group of 79 clients and a follow-up
rate of 100% for the selected group of 20 clients who were interviewed three times.
Regardless of category of client, findings demonstrate an improvement over time for
the outcome variables: general attitude to offending, anticipation of re-offending and
perception of current life problems. However, these results were short-lived for many
prisoners, who failed to sustain the gains made. Interviews with the cohort of 20
suggest that clients who did not receive continuity of treatment after the programme, in
terms of case management and structured treatment, did not fare as well as those who
received such treatment. However, the study failed to demonstrate any significant
change for the outcome variables victim hurt, denial and evaluation of crime.
In 2006 the HSE published the results of an 18-month process evaluation and
treatment outcome study of 40 female drug-using prisoners admitted to the Dóchas
Centre (Comiskey, C.M, et al. 2006). The aim of the study was to model the care
pathway of the women and to discover whether their experiences in the Dóchas Centre
had a positive or negative impact on their lives. The women were interviewed within
one month of committal and again six months later. Qualitative interviews were also
conducted with eight people working in a number of capacities with women who had
been in prison.
Of the original cohort of 40 women, outcome data was obtained for 39, and 27
completed a second interview. The women ranged in age from 16 to 43 years; 23 had
children under the age of 18, most of whom did not live with their mothers. The majority
of the women had completed their education by the age of 15.The study measured key
variables, including drug use, accommodation, health, psychosocial functioning and
involvement in crime before the women were admitted to the Dóchas Centre, during
158
their imprisonment and after their release. The strongest positive outcomes were in the
area of crime. There was a significant reduction between baseline interview and sixmonth follow-up in the proportion of women who committed crimes, apart from the
crime of soliciting, which showed a slightly increased incidence.
There was a significant reduction in the levels of heroin use. On average, the women
who were using heroin at recruitment stage did so at least once a day. At follow-up,
this had reduced to twice a week. Slight reductions were noted in the numbers of
women using cocaine, non-prescription methadone and ecstasy. However, the
physical and mental health of the women showed only minor improvements at followup and, in some cases, there was evidence of deterioration. Of particular concern was
the finding that three of the women interviewed had attempted suicide since leaving
prison.
One of the main findings was the considerable risks that the women were exposed to
after release, including overdose, gang rape, prostitution, homelessness and polydrug
use. Of the 22 women who were released during the six-month follow-up period, only
seven returned home and did not report any trauma. Three of the original cohort of 40
women died during the six-month follow-up period; all three had been released from
the Dóchas Centre. These findings demonstrate the real and significant risks
associated with the release of female drug-using prisoners. The majority of women who
were interviewed at six-month follow-up felt that the time spent in the Dóchas Centre
had been of some help, for example assisting with drug treatment, educational
opportunities and a break from the stress of their lives. Women expressed a number of
negative criticisms of the services they received. Over half of the women had concerns
at the time of their release relating to, for example, a lack of suitable accommodation,
money worries, concerns surrounding their children and a fear of returning to drug use.
The women were asked whether they had received help with these issues on being
released. Of the 20 women who answered the question, only three had received
assistance. In addition, only four of the 27 women interviewed at follow-up stated that
they had had any contact with social welfare services while in prison. Finally, 16 of the
22 women who were released during the time between baseline interview and followup were not given advance indication of their release date, which had implications for
their vulnerability on release.
A key finding from the qualitative interviews with the eight participants who worked with
women who had been in prison was the lack of co-ordination between the various inreach services to the women’s prison. These participants felt that, while the current
range and number of agencies providing in-reach services was sufficient, the lack of
integration between the services often resulted in poorer outcomes for the women.
They stressed the need for appropriate accommodation that took into account the
specific requirements of drug-using women who had been in prison.
The findings of the study indicate that the women experienced some positive effects on
their lives in the six-month period between recruitment and follow-up interview. It is
unclear whether the improvements noted in the report can be attributed to the Dóchas
Centre or to the stage which the women were at in their drug-using careers. The
author suggested that further longitudinal information on the women and their care
processes would be required in order to answer this question..
The provision of treatment immediately on release plays an important part in reducing
drug-related deaths. The 2009 IPS annual report stated that the IPS continued to face
challenges in securing places in methadone clinics in the community for prisoners on
methadone who were to be released (Irish Prison Service 2010). In May 2010, the Irish
Penal Reform Trust (IPRT) published a report ‘It’s like stepping on a landmine…’ –
reintegration of prisoners in Ireland (Martynowicz and Quigley 2010).
The study, conducted between October 2009 and February 2010, consisted of a
literature review, a number of semi-structured interviews with service providers (in the
159
statutory and non-statutory sectors), a questionnaire completed by service providers
throughout Ireland, and two focus groups with ex-prisoners in Dublin. The aims of the
study were to:
 review national and international practice and policy (including human rights
standards) relating to reintegration,
 identify barriers to reintegration of ex-prisoners in Ireland,
 map, as far as possible, available services and identify possible gaps in service
provision, and
 make recommendations for development of future policy and practice.
The study found that, although ‘significant progress has been made in recent years in
integrating post-release services ... by the Irish Prison Service and its partners, there
remains a less than uniform approach to the provision of necessary services in
individual prisons and access to support is dependent on the facility in which the
prisoner finds his- or herself’ (p. 3). Service provision also varied between different
areas of the country. The study also found that the unstructured use of Temporary
Release, often used to alleviate pressure on overcrowded prisons and to make spaces
available for new prisoners, impacts negatively on preparation for release. The study
found that prisoners are sometimes given no more than a few hours’ notice before
being released, and some are released when outside services are unavailable, for
example on Friday evenings or at the weekend.
The report noted some positive developments in recent years, such as the
development of a system of Integrated Sentence Management (ISM) in some prisons,
and wider provision of drug counselling services, including those provided in Dublin by
MQI (see Section 11.4 above). The IPRT makes a number of recommendations arising
from the findings of the study, including the following:
 The IPS should provide appropriate access and facilities for practitioners working
with prisoners on drug and alcohol addictions, including the provision of facilities
ensuring confidentiality and a therapeutic environment for service users.
 All prisons should provide drug-free landings.
 The IPS, in partnership with relevant service providers, should ensure
arrangements are made for prisoners to continue drug and alcohol addiction
treatment upon release when required.
 The government should make the introduction of spent convictions legislation a
priority, to assist prisoners in entering employment post release (see Chapter 1.2.1)
for an update on this proposed legislation).
Methodological limitations and information gaps
The regular compilation and reporting of data in relation to drug treatment provision in
Irish prisons is hampered by resource limitations. For example, the provision of data to
the NDTRS is dependent upon the ability of treatment providers to supply the relevant
data and this is likely to be adversely affected by prison overcrowding and stretched
resources. On the other hand, the contracting-out of services to non-prison-based
services is beneficial in that data are no longer collected by just one source. Although
the IPS provides data in its annual reports, these reports are generally not published
until nine months after the reporting period.
A study is currently being carried out by the National Advisory Committee on Drugs
(NACD) to determine the need for drug treatment and harm reduction (including needle
exchange) services in Irish prisons (Jean Long, personal communication, NACD
committee member, 2010). The aims of the study are to:
 describe the nature, extent and pattern of consumption of different drugs among
the prisoner population when in the community and when in prison;
 describe methods of drug use, including intravenous drug use, among the prisoner
population;
 estimate the prevalence of blood-borne viruses among the prisoner population and
to identify associated risk behaviours; and
160

measure the uptake of individual drug treatment and harm reduction interventions
(including hepatitis B vaccination) when in the community and when in prison.
The study is based on a randomly selected sample of more than 800 inmates
(sentenced and remand) in Irish prisons, who are invited to complete a selfadministered questionnaire and provide two oral fluid samples, one to be tested for
drugs and one for blood-borne viruses. Participation is voluntary. The study is due to
be published in 2012.
161
12. Drug users with children (addicted parents, parenting,
child care and related issues)
12.1
Introduction
The start date for reporting material for this selected issue is 1996, chosen because the
issue of drug-using parents with children was first identified as an issue in a national
drug policy document in that year.18
Data on the number of drug-using parents and their children are routinely collected in
the four-yearly general population drug use prevalence survey and the National Drug
Treatment Reporting System (NDTRS). Since the mid 1990s, there has also been a
steady output of research from Dublin’s maternity hospitals regarding drug-using
pregnant women and their babies. Research into the experiences and risk profiles of
drug-using parents and their children has been less sustained. Following an empirical
study of the impact of parental drug use on children’s day-to-day lives within families in
Dublin in the late 1990s, there has been no further research focusing specifically on
children living with parents who use drugs. However, the authors of other research
reports have indicated the need to research what amount to ‘hidden populations’ of
children whose parents use drugs, e.g. young carers, children in the traveller
community whose parents use drugs, and children whose parents are in prison and
use drugs, and to explore their particular experiences, vulnerabilities and risk profiles.
There is no dedicated policy or legislation targeting drug-using parents and their
children. Instead, sectoral strategies and legislative measures providing generally for
those under the age of 18 may make specific mention of children whose parents use
drugs. Policy has shifted in recent years from a focus on child protection to prevention
and family support.
With regard to responses, clinical and medical services and guidelines have been
developed for working with pregnant women who are opiate users and for caring for the
babies of these women. In addition, childcare services to enable parents to participate
in drug treatment and rehabilitation programmes, and targeted family support and child
development programmes, are provided. However, the researchers who have pointed
to the existence of ‘hidden populations’ of children of drug-using parents have also
highlighted the need for specific services targeting these populations.
Statutory services to ensure the welfare and protection of all children aged under 18
years include guidelines which identify parental drug or alcohol use as a risk factor
leading to a welfare concern. In recent years delivery of these statutory services has
been found to be inconsistent and the delivery system is currently being revised and
strengthened, and specialised training is being provided. The need for adequate
training for professionals working with drugs-users who are parents is an issue
highlighted at the conclusion of many Irish research studies, to ensure these
professionals are prepared and sufficiently sensitive and responsive to what are often
complex and always unique situations.
12.2
Size of the problem
12.2.1 Studies or data collection on the prevalence and characteristics of drug
using pregnant women and parents
Drug users in general population with children
18
See the First report of the ministerial task force on measures to reduce the demand for drugs Ministerial Task Force
on Measures to Reduce the Demand for Drugs (1996). First report of the ministerial task force on measures to reduce
the demand for drugs. pp. 92. Stationery Office, Dublin. .The problem of pregnant drug-users had first been noted in
Ireland in 1981 Farrell, E. (2001). Women, children and drug use. In A collection of papers on drug issues in Ireland,
Moran, R., Dillon, L., O'Brien, M., Mayock, P., Farrell, E. and Pike, B. (eds) Health Research Board, Dublin, pp. 153-177
162
The general population all-Ireland drug prevalence survey, administered in 2002/3 and
2006/7 by the National Advisory Committee on Drugs (NACD) and the Public Health
Information and Research Branch (PHIRB), have recorded whether or not the
respondent has dependent children. Not all respondents were problem drug users.
Unpublished data from the 2006/7 survey (National Advisory Committee on Drugs and
Drug and Alcohol Information and Research Unit 2008) are reported here.
In 2006/7, 37% (1861/4967) of all respondents who had used drugs had dependent
children aged 18 years or younger, and 50% of these children were aged five years or
younger. As Figure 12.2.1.1 shows, among these parents, the most commonly used
substances were alcohol (91% ever used) and tobacco (60% ever used). Just over
23% had used any illegal drug in their lifetime and only 4.3% had used any illegal drug
in the last year, with cannabis being the most commonly used substance. After
cannabis, over-the-counter and prescription drugs, including anti-depressants,
sedatives and tranquilisers, and other opiates, were the most common substances ever
used or used in the last year.
The characteristics of those respondents with dependent children who had used in the
last year differed from those with dependent children who had ever used but not in the
last year (see Figure 12.2.1.2). Among those with dependent children who had used in
the last year, a larger proportion were male (58%) and were younger (nearly half aged
between 15 and 34 years). Three-quarters of those with children who had used drugs
but not in the last year lived their own home, while only half of parents who had used
drugs in the last year owned their own home.
Figure 12.2.1.3 compares the occupational status of respondents with dependent
children aged 18 or younger who had ever used drugs, and those who had used drugs
in the last year. More respondents who had used drugs but not in the last year were in
paid employment or working in the home than respondents who had used drugs in the
last year. For all other occupational categories, including self-employment, not in the
paid work-force or in training or education, the proportions were reversed, with parents
who had used drugs in the last year exceeding those who had not used in the last year.
Figure 12.2.1.1 All-Ireland General Population Drug Prevalence Survey, 2006/7: Lifetime and last
year drug use prevalence, by drug, among respondents with dependent children aged 18 or
younger
100 91.7
86
90
80
70
60.3
% 60
50
40
30
38.1
Ever used
23.3
20
10
4.3
21.4
Last year
11.5
10.3
7.5
5.1
4.6
4.6
4.4
3.7 4.9
3.4
2.2
0.9
0.3
0.2
0.4
0
Source: unpublished data, NACD 2011
*’Any illegal drug’ refers to the reported use of one or more of the following: amphetamines, cannabis, cocaine powder, crack, ecstasy,
heroin, LSD, magic mushrooms, poppers or solvents.
** ‘Sedatives’ include tranquilisers.
*** ‘Other opiates’ include Opium, Temgesic®, Diconal®, Napps, MSTs®, Pethidine, DF118® (Dihydrocodeine),
Buprenorphine and Morphine, Codeine, Kapake, Diffs, Dikes, Peach, Fentanyl (Durogesic®, Sublimaze®, Actiq®), Oxycodone
(Oxycontin®, Oxynorm®), and Buprenorphine (Subutex®).
163
Figure 12.2.1.2 All-Ireland General Population Drug Prevalence Survey, 2006/7: Comparison of
demographic characteristics of respondents with dependent children aged 18 or younger who had
ever used or had used in the last year
80
74.3
74.2
58.0
60
49.3
47.5
%
43.5
37.0
40
33.5
Ever used
20
Last year
0
Male
Aged 15-34
Married
House owner
Source: unpublished data, NACD 2011
Figure 12.2.1.3 All-Ireland General Population Drug Prevalence Survey, 2006/7: Comparison of
occupational status of respondents with dependent children aged 18 or younger who had ever
used or had used in the last year
70
60
60.0
50
%
40
50.6
30
20
10
20.0
16.0
Ever used
7.4
11.0
0
10.0
3.7
2.6
1.6
3.7
3.7
0.2
1.3
2.4
0.1
1.2
Last year
0.1
Source: unpublished data, NACD 2011
Drug users in treatment with children
The National Drug Treatment Reporting System (NDTRS) records the living
circumstances of drug treatment clients, including whether they live with their children,
and whether with a partner or alone.19 The age and number of these children are not
recorded in the NDTRS.
The data show that between 2003 and 2009 the proportion of clients in drug treatment
who reported living with their children remained relatively stable. The proportion
reporting that they lived with a partner and children ranged between 10.2% and 10.8%,
and the proportion reporting that they lived alone with children ranged between 3.7%
and 4.6%.
Figure 12.2.1.4 breaks down these proportions by gender. It shows that the proportion
of men in drug treatment who lived with their children and partner remained very stable
between 2003 and 2009, ranging between 10.5% and 10.8%. The proportion of women
in treatment living in similar circumstances was higher, ranging between 13.4% and
14.8%. A very small proportion of men in drug treatment lived alone with their children
(ranging from 0.3% to 0.6% over the reporting period), while the proportion of women
living alone with their children was much higher. The percentages fluctuated over the
period, but overall the trend shows an increase of 2.4%, from 13.7% in 2003 to 16.1%
in 2009.
19
The NDTRS requires that one form be completed for each new client coming for first treatment and for each
previously treated client returning to treatment for problem drug and/or alcohol use in a calendar year. In the case of the
data for ‘previously treated cases’, there is a possibility that individuals appear more than once in the database: for
example, where a person receives treatment at more than one centre.
164
Percentage of all cases in treatment
Figure 12.2.1.4 Proportion of clients in drug treatment who live with children, by gender, 2003–2009
18
16.7
17
16.1
15.9
15.1
16
14.8
14.6
14.5
13.9
13.7
13.5
13.5
13.4
14
12
10.5
10.8
10.2
10.8
10.6
10.7
10.5
10
Women - partner and childr
8
Women - alone with childre
6
Men - partner and children
4
2
Men - alone with children
0.5
0.6
0.5
0.3
0.4
0.6
0.6
2003
2004
2005
2006
2007
2008
2009
0
Source: unpublished data, NDTRS 2011
The greater frequency of women in drug treatment who are also heads of lone parent
families, compared to men, reflects the national trend. Reporting the results of the 2006
population census, the Central Statistics Office (CSO) stated that the number of lone
parent families had increased by 23% since 2002, and that lone mothers, where all of
the children were under 15 years, showed the greatest increase (57.6%). In all, nearly
86% of lone parent families were headed by females (Central Statistics Office 2007).
Drug use prevalence among pregnant women
The use of psychoactive substances by pregnant women attending two separate urban
maternity hospitals in Dublin has been well documented.
In a study conducted in the Rotunda Hospital in 1992, Bosio and colleagues (Bosio, et
al. 1997) found that the prevalence of chemical substance abuse in 504 antenatal urine
samples was 2.8%; among the postnatal population (515 samples) the prevalence of
drug abuse, excluding alcohol, was 6%. The substances found included
benzodiazepines, cannabis, amphetamines, opiates, and cocaine. A subsequent study
(Lyons, Fiona, et al. 1999) found that in 1996,20 4% of 522 antenatal urine samples
were positive for substances abuse. By applying the single urinalysis test to the women
as they were admitted to labour rather than when they attended for a scheduled antenatal clinic, the authors believed the risk of under-representation was reduced.
Barry and colleagues (Barry, Siobhan, et al. 2006) analysed routine clinical data
collected on over 120,000 pregnant women in the Coombe Women and Infants
University Hospital (CWIUH), Dublin, between 1987 and 2005. The objective was to
describe the reported prevalence and patterns of alcohol and nicotine use in women
attending the hospital during the whole period, and to describe the reported prevalence
and patterns of illicit drug use and polysubstance use among women attending since
1999. These data were self-reported and collected over 20 years by staff whose main
priority was clinical care of pregnant women rather than the gathering of
epidemiological data. Thus, standardisation of data collection methods and validation
of data were not deemed possible.
In all, 447 (4.57%) of all pregnant women who registered at the CWIUH between 1999
and 2005 reported having used illicit drugs in pregnancy. Methadone was the
20
While Lyons and colleagues did not report when they collected their data, they noted that their study was conducted
at the same time as that by Coghlan and colleagues Coghlan, D., Milner, M., Clarke, T., Lambert, I., McDermott, C.,
McNally, M. et al. (1999). Neonatal abstinence syndrome. Irish Medical Journal, 92, (1), 232-233, 236. Available at
www.drugsandalcohol.ie/6515/ (1999), who reported that their data had been collected in 1996.
165
substance most frequently reported (323, 72%). Methadone and diazepam were
reportedly obtained from a combination of prescribed and illicit sources; the other
reported drugs (cannabis, heroin, ecstasy and cocaine) were all obtained illicitly.
The authors recommended that the feasibility of routine collection of ante-natal alcohol,
tobacco and illicit drug use in all hospital and primary care settings should be
determined, and on the basis of this feasibility study routine ante-natal monitoring of
substance use should be introduced.
A more recent study by Cleary and colleagues (Cleary, et al. 2011) reported on a
retrospective cohort study of 61,030 singleton births at the CWIUH between 2000 and
2007, based on antenatal, delivery and postnatal records and the Central Treatment
List (of clients prescribed methadone). The aim was to investigate the relationship
between methadone maintenance treatment and maternal characteristics and perinatal
outcomes. Unlike many previous studies, it was a population-based study rather than a
sample-based study, which enabled possibly confounding socio-demographic factors to
be controlled for. The study found that 618 women (1%) were on methadone at
delivery.
Characteristics of drug-using pregnant women
Bosio and colleagues (Bosio, et al. 1997) whose study is described above, found that
substance abusers in pregnancy were more likely to be single, unemployed, and to
have had a previous pregnancy. Cleary and colleagues (Cleary, et al. 2011), whose
study is also described above, reported that methadone-exposed women were more
likely to be younger, unemployed, Irish, unmarried, have had previous pregnancies,
have an unplanned pregnancy, to book antenatal care later than 20 weeks into
pregnancy, to be current smokers and to drink alcohol before pregnancy. In addition,
and as expected, a higher proportion of methadone-exposed women were likely to test
positive for hepatitis B, hepatitis C and HIV when compared to non-exposed women
(Table 12.2.1.1).
Table 12.2.1.1 Blood-borne viral status among methadone-exposed mothers, among all singleton
births at CWIUH, 2000–2007
Exposed to methadone*
Non-exposed*
Hepatitis B positive serological
status
20 (3.5%)
326 (1.0%)
Hepatitis C positive
serological status
275 (48.2%)
193 (0.6%)
HIV positive
35 (5.8%)
171 (0.3%)
*The total number tested in each group is not presented in the paper.
Source: (Cleary, et al. 2011)
12.2.2 Studies or data collection on the physical, mental and other risks/harms
among drug using pregnant women / parents and their children
Drug-using pregnant women and the new-born
Transmission of infectious diseases
A prospective study was initiated to determine the vertical transmission rate (VTR) of
HIV and the average age of infant seroreversion, and to monitor clinical, immunologic
and virologic evidence for HIV infection in seroreverters (Nourse, et al. 1998). Ninetythree HIV positive infants were identified between 1985 and 1998. The predominant
underlying maternal risk factor for HIV infection was found to be intravenous drug use
(96%). Of the 93 infants, median gestational age was 40 weeks and median birth
weight 3,125g. Ninety-four per cent of infants were bottle fed. At the time of the study,
72 (77%) infants were uninfected, 12 (13%) infected, 4 (4.5%) found to be
indeterminate and 5 (5.5%) had been lost to follow-up. The intermediate estimate of
VTR was 14.3%. The median age at documented seroreversion was 12 months. No
significant differences were found between infected and non-infected children in
male/female ratio, gestational age, mode of delivery or birthweight.
166
Premature birth and/or neonatal abstinence syndrome
Coghlan and colleagues (Coghlan, et al. 1999) undertook a retrospective review of
maternal and infant records of the 43 infants admitted with neonatal abstinence
syndrome to the neonatal intensive care unit of the Rotunda Hospital, Dublin, in 1996.
The relationship of maternal drug abuse to symptoms, the effectiveness of
pharmacologic agents in controlling symptoms and the length of inpatient stay were
investigated.
Those infants with a serial Finnegan score greater than 8 were treated. The average
maternal age was 24.6 years (18-34 years) and drug use included a range of
substances, often combined, including methadone, benzodiazepines, heroin, oral
morphine sulphate, dothiepin and cannabis. Average gestational age was 40.3 (35–42
weeks). The average birthweight was 2.81 kgs (1.89–3.91 kgs). Time to onset of
withdrawal symptoms was 2.8 (1–13) days. The duration of pharmacologic treatment
(oral morphine sulphate and/or phenobarbitone) was 21.8 (1–62) days.21
This study confirmed that polydrug abuse was the commonest type of drug abuse in
pregnant women attending maternity hospitals in Dublin. The duration of withdrawal
symptoms was loosely related to drug type, but increasing duration of symptoms was
noted for infants exposed to benzodiazepines.
Scully and colleagues (Scully, Mike, et al. 2004) reviewed the clinical records relating
to the 111 referrals to the Drug Liaison Midwife (DLM) in the CWIUH from April 1999 to
April 2000. Eighty-three women were in treatment for substance abuse when referred
to the drug liaison midwife. In total, 53 women were assessed as opiate unstable and
21 were benzodiazepine unstable.
Thirteen per cent of the women had a caesarean section, which was lower than the
proportion of caesarean sections (16%) for all maternity cases at the hospital in 1999.
Mean gestation at delivery was 38.45 weeks. Almost 11% of infants were delivered
prematurely, which was higher than the proportion of premature deliveries (6%) for all
maternity cases at the hospital in 1999. The mean birthweight of the babies was
2,949g.
The authors reported that, of the cohort of 111 women, 85 (75%) were being
prescribed methadone at the time of delivery and their infants’ withdrawal status was
known. With a view to examining the risk factors for infant withdrawals, the researchers
recorded maternal methadone dose at delivery, their alcohol and tobacco use status
and the presence of positive urinalysis for other opioids, benzodiazepines and cocaine
one month pre-delivery.22 Maternal methadone doses, which ranged from 5 to 95 mg,
were classified into three levels, each containing a similar number of women: low, n =
29 (5–30 mg); medium, n = 28 (31–50 mg); and high, n = 28 (51–95 mg).
Forty infants (47%) received a diagnosis of Neonatal Abstinence Syndrome (NAS)
using the Finnegan neonatal abstinence scoring system. The chi-square test for trend
indicated that there was a significant dose–response relationship between maternal
methadone dose at delivery and the occurrence of withdrawals (p = .001).
Respectively, withdrawal occurred in 28% (8/29), 43% (12/28) and 71% (20/28) of
infants delivered to women at low, medium, and high doses.
The presence of opioids other than methadone in the month before delivery and the
mother’s alcohol use status were not related to the occurrence of infant withdrawal.
However, a significant association was found between infant withdrawal and mother’s
benzodiazepine use (m2 = 4.377, df = 1, p < .05). None of the associations between
frequency of withdrawal and adequacy of prenatal appointment attendance, admission
for benzodiazepine stabilisation or for opioid stabilisation were statistically significant.
21
The numbers given in brackets are the range of results for each variable.
Because only three women were non-smokers and three used cocaine, these variables were omitted from the
analysis.
22
167
Multivariate logistic regression indicated that benzodiazepine use was not
independently associated with withdrawal (adjusted OR = 1.704, 95% CI: 0.554–
5.238), whereas high maternal methadone dose at delivery remained a significant risk
factor (adjusted OR = 4.862, 95% CI: 1.166–20.273).
Carmody and colleagues (Carmody, et al. 2011) examined maternal and neonatal
outcomes of 436 pregnant women referred to the DLM at the CWIUH between 2002
and 2007, and who were attending a methadone clinic at the time they gave birth. The
researchers compared their findings with those of the earlier study (Scully, Mike, et al.
2004).
The authors found that a very high proportion (93%) of the 2002–2007 cohort was
taking prescribed methadone, compared to the 1999–2000 cohort (75%). The average
dose of methadone at delivery was higher for the later cohort (60mg) than for the
earlier cohort (39 mg). The average gestation at delivery was 38 weeks for both
cohorts. The average birth weight was higher by 66g in the later cohort. The
percentage of babies requiring admission to the special care baby unit (SCBU) had
increased from 42% in the earlier cohort to 56% in the later cohort. The proportion of
babies requiring treatment for neonatal abstinence syndrome was considerably higher
in the later cohort (45%) than in the earlier cohort (29%), and the babies’ average
length of stay in the SCBU increased by over 2 days in the later cohort.
The authors noted that their findings were part of a larger study that will examine
changes in maternal methadone doses, opioid stability at delivery and whether there is
a correlation between maternal methadone dose and neonatal abstinence syndrome
(NAS). While acknowledging that information on incidence and outcomes for mothers
and babies is useful in planning treatment services, the authors also observed that their
study did not ask women their opinions: ‘A qualitative research will address some of the
issues from their perspective, acknowledge their needs and improve their quality of
care’ (Carmody, et al. 2011) p. 450.
Cleary and colleagues (Cleary, et al. 2011), whose study of 61,030 singleton births at
the CWIUH between 2000 and 2007 is described in section 12.2.1 above, found that
methadone exposure among the mothers was associated with an increased risk of very
preterm birth (<32 weeks of gestation), being small for gestational age (<10th
percentile), admission to the neonatal unit, and diagnosis of a major congenital
abnormality. There were four cases of Pierre Robin sequence among 618 methadoneexposed babies, compared to eight cases in 60,412 non-exposed infants. Although not
statistically significant, the proportion of deaths within the first six weeks of birth was
three times higher among the methadone-exposed group (2.4%) than the non-exposed
group (0.8%).
The authors also found a dose-response relationship between methadone and
neonatal abstinence syndrome. As the mother’s methadone dose increased so did the
incidence of neonatal abstinence syndrome (see Table 12.2.2.1). Preterm birth and
small gestational age also predicted the presence of neonatal abstinence syndrome.
Table 12.2.2.1 Methadone dose and its relationship with neonatal abstinence syndrome among
methadone-exposed mothers, among all singleton births at CWIUH, 2000–2007 (n=615)
Neonatal abstinence syndrome
Methadone dose in mg
Present
Absent
Adjusted odds ratios
(95% CI)*
<21
19 (23.8)
61 (76.2)
1
21–50
73 (33.3)
146 (66.7)
0.9–3.5
51–80
117 (47.4)
130 (52.6)
1.6–6.53
81–100
26 (48.1)
28 (51.8)
1.3–7.5
>100
11 (73.3)
4 (26.7)
2.5–48.0
*Adjusted for preterm birth, gestational age, gender, maternal smoking during pregnancy and alcohol use before pregnancy
Source: (Cleary, et al. 2011)
After controlling for known adverse socio-demographic factors, methadone exposure
was found to be associated with an increased risk of adverse perinatal outcomes.
168
Methadone dose at delivery was one of the important determinants of neonatal
abstinence syndrome.
Opiate-using pregnant women: 20-year follow-up
Whitty and O’Connor (Whitty and O'Connor 2007) examined the 20-year outcome for
55 women who were pregnant, using opiates and attending a drug treatment centre in
Dublin in 1985. They found that 29 women (53%) had died. Among these 29 women,
HIV was the commonest cause of death, accounting for 17 (59%). Among the 16 still
living, 84% were unemployed, 74% were using illicit substances, and 78% were living
in state-subsidised accommodation. The authors concluded that mortality was higher in
this group than among other long-term follow-up samples.
Children living with drug-using parents
In what has been described as ‘seminal’ work, Diane Hogan led an empirical
investigation between 1996 and 1999 into the impact of parental opiate use on
children’s day-to-day life within families. The focus on the ‘fabric of ordinary daily life’
was based on the view that ‘it is difficult to design appropriate policies and services for
drug users and their families in the absence of an understanding of the processes by
which drug use, parenting and children’s well-being are connected’ ((Hogan and
Higgins 2001): 5).
The research focused on primary-school-aged children in the care of at least one
opiate-using parent. Following an exploratory study involving 10 families (Hogan and
Higgins 1997), the main study investigated 100 families living in two locations in Dublin
where residents generally experienced profound social and economic disadvantage
and where there was a high incidence of illicit drug use (Hogan and Higgins 2000). The
sample comprised 50 families in which at least one parent was dependent on opiates
(heroin or methadone), and their experiences were compared with those of a matched
comparison group of 50 families from the same areas of Dublin who had a similar
socio-economic background but in which neither parent was a drug user.
Data were collected by means of in-depth interviews with the 100 parents, two focus
groups with professionals working with the drug user and/or their children, and a survey
questionnaire in 26 schools with the teachers of some of the children. Owing to drugusing parents’ reluctance during the exploratory phase to involve their children directly
in the research, it was decided to focus on the views of adults.
The researchers identified four key ways in which parental drug use might impact on a
child’s daily life ((Hogan and Higgins 2001): 31):
 disruption of parenting and care owing to short or long term separation,
 exposure to parents’ drug use including contact with police or prisons,
 children’s emotional well-being may be affected by worrying about their parents and
the impact of their parents lifestyle, including the assumption of adult caring roles,
experience social isolation in the community and school, and
 children’s academic progress may be affected by poor attendance and low levels of
parental involvement.
With respect to parents’ perceptions of how their drug use had affected their parenting
capacity and family processes, Hogan (Hogan 2007) identified three broad sets of
contextual factors to which parents attributed their perceived unsatisfactory parenting,
in particular their unavailability and instability.
 The acquisition and ingestion of drugs, imprisonment, attendance and treatment
facilities and hospitalisation, reduced parental availability.
 Physiological factors, such as intoxication and withdrawal from opiates, reduced
parent’s emotional responsiveness.
 Psychological factors, such as preoccupation with drugs and instability of moods,
undermined discipline and limit-setting. While some non-drug-using parents also
experienced volatility in parenting style, and especially in relation to limit setting, no
clear systemic relationship emerged that appeared to provide an over-riding
169
contextual explanation for their approach to parenting, as it could for drug-using
parents.
With regard to the danger of children being the victims of drug-related violence,
Hogan’s research implies it was not critical issue for the children of the opiatedependent parents included in the study: ‘… in evaluating the impact of their drug
dependence on their parenting, most drug users distinguished between the physical
and emotional needs of their children. Most believed that even when their heroin use
was intensive and their own resources low, their children’s physical needs were
catered for adequately, albeit often by another family member rather than by
themselves.’ ((Hogan 2007): p. 628)
Another study of drug-using parents attending an aftercare programme found similar
results (McKeown and Fitzgerald 2006). Parents’ strengths were in the areas of
communication and involvement, while the main weakness was perceived to be in
setting limits. It was found that respondents used much more discipline on their
children compared to the average Irish parent. However, they used non-violent
discipline and psychological aggression more frequently than the average Irish parent,
with minor physical assaults occurring much less frequently and severe physical
assault infrequently.
Drug use in later life by children of drug-using parents
Hogan and Higgins, whose study is described above, could not offer any conclusions
about the impact of children’s exposure to drugs, through witnessing their parents drugrelated activities, on their own subsequent drug use. However, on the basis of their
findings, they suggested a future direction for drug prevention among children of drug
users ((Hogan and Higgins 2000)). They had found that while parents disapproved of
their own drug use, and did not want their children to use drugs, they were not
successful in transmitting these values to their children. The parents’ drug use and
treatment were shrouded in secrecy, and as a result the parents’ views were not clearly
communicated. Moreover, the parents, like others in their communities, overtly
condemned ‘junkies’, but at the same time, according to most parents, their children
knew about or suspected their parents’ drug use. The result was confusion in the minds
of the children. The researchers called for these discrepancies between parents’ goals
and practices to be the focus of future prevention interventions.
Homeless young people
The Youth Homelessness Strategy (YHS) (Department of Health and Children 2001)
reported that 5% (30/588) of children who presented to the health boards in 2000 as
homeless did so because of parental abuse of alcohol or drugs. In his report on child
protection in Ireland, Shannon (Shannon 2010) noted that recent research ((Mayock
and Vekic 2006); (Mayock and Carr 2008)) confirmed that the presence of parental
alcohol or drug addiction continued to be a key indicator of an increased likelihood of
young people leaving home.
Hidden populations
The variety of living circumstances of children living with drug-using parents, and the
associated risks, are not well understood. Two Irish researchers who have mounted
major qualitative studies on, respectively, the children of drug-using parents and on
mothers who used drugs, have called for research that directly accesses the children of
drug-using parents in order to foreground their experiences and perceptions and reach
a fuller understanding of their vulnerabilities and risk exposure (Hogan 2007): p. 633;
(Woods 2008): p. 287).
Other Irish studies have suggested that children of drug-using parents may live in
circumstances where their vulnerability is difficult to detect – for example, young carers
looking after parents with drug or alcohol addictions (Fives, et al. 2010), or children of
traveller parents (Fountain 2006), (All Ireland Traveller Health Study Team and School
of Public Health Physiotherapy and Population Science University College Dublin
170
2010), (Van Hout, M.C. 2009). In such cases, families do not want people to know the
circumstances within which a child is providing care; they may fear that the child may
be taken away by social services.
Two studies have been undertaken in the last decade on the impact of imprisonment
on family members 2001 (King, Dervla 2002) (Bedford Row Family Project 2007). In
the earlier study, King (King, Dervla 2002) noted the disadvantaged background of
many prisoners and the reportedly high incidence of drug use within Irish prisons, with
significant numbers of prisoners starting or continuing to use drugs during their
sentence. He suggested that these factors were significant for the children of prisoners,
who might be at risk of disadvantage even before their parent was imprisoned, and
were therefore in need of special support at all stages of their parent’s sentence.
12.3
Policy and legal frameworks
12.3.1 Policies addressing drug using parents / pregnant women and their
children
National policies that specifically address drug-using parents and their children
No specific national policy on drug-using parents and their children has been
developed in Ireland.
Other relevant policies targeting vulnerable groups (which could include drugusing parents and their children)
Low birthweight is one of three core targets to reduce health inequalities in Ireland
(Institute of Public Health 2001). In 2005 a study was commissioned to quantify and
assess the effect of socio-economic status on low birthweight in Ireland and consider
these findings in the light of the NAPS target (McAvoy, et al. 2006). Among other
things, this study found that the number of babies born to opiate-using mothers in
Ireland was relatively small but that those babies were born to mothers at the lowest
end of the socioeconomic scale and that the risks experienced by these babies were
exceptionally high. The authors concluded that although, in tackling health inequalities,
it is important to target drug using mothers, reducing low birthweight related to drug use
would only have a small impact at a population level. They recommended that the
issue be kept under review in light of changing drug-use patterns and emerging data.
Objectives of national or local drug strategies/action plans that specifically
target drug-using parents and their children
In 2001 the National Drugs Strategy 2001–2008 (Department of Tourism Sport and
Recreation 2001) called for consideration of how to integrate child-care facilities with
treatment and rehabilitation centres and how best to provide child care in a residential
treatment setting (Action 54). Four years later the Steering Group that reviewed the
National Drugs Strategy (Department of Community Rural and Gaeltacht Affairs 2005)
noted that the health services considered that full-time childcare facilities within an
addiction setting might lead to further stigmatisation of children of drug misusers, and
more appropriate services, such as drop-in play/crèche areas rather than full-time
facilities, should be provided.
Endorsing a recommendation by the Working Group on Drugs Rehabilitation (Working
Group on drugs rehabilitation 2007), the National Drugs Strategy 2009–2016
(Department of Community Rural and Gaeltacht Affairs 2009) called for further work to
facilitate closer engagement between child, outreach and drug services at a local level,
consider ways to address the needs of the children of problem drug users, and
establish and disseminate best practice. However, the strategy did not include any
specific actions in this regard.
In 2009, for the first time in official policy, the children of drug-users were identified as a
‘group at risk’ (Department of Community Rural and Gaeltacht Affairs 2009). Action 29
171
of the new strategy called for the development of prevention measures that focus
specifically on the family, including supports for families experiencing difficulties due to
drug/alcohol use, parenting skills, and ‘targeted measures focusing on the children of
problem drug and/or alcohol users aimed at breaking the cycle and safeguarding the
next generation’.
In 2007, the need for research to ascertain the number of children with drug misusing
parents, the issues this raised and best practice in relation to integrating childcare into
treatment and rehabilitation services was identified (Working Group on drugs
rehabilitation 2007). The National Advisory Committee on Drugs commissioned
research on the matter (Horgan 2011). Published in October 2011, the report consisted
of a comprehensive review of the Irish and international literature on what is known
about the impact of parental use of various substances on their children. The report
concluded with recommendations for future policy and research in four key areas:
 research, information and data needs,
 recognise the different needs of young children and adolescents with regard to
parental substance misuse,
 reduce the negative impact of parental substance use on children and the family as
a whole,
 health promotion and public information.
12.3.2 Legal frameworks addressing drug using parents/pregnant women and
their children
Under the Child Care Act 1991, the Health Service Executive (HSE) has a statutory
duty to promote the welfare of children (i.e. aged under 18 years) who are not receiving
adequate care and protection. When carrying out its statutory duty the HSE must have
regard to the following: (1) it is generally in the best interests of the child to be brought
up in his/her own family, and (2) having regard to the rights and duties of the parents,
the welfare of the child is the first and paramount consideration and that, as far as is
practicable, the wishes of the child should be considered. The Act requires the HSE to
identify children who are not receiving adequate care and protection, co-ordinate all
relevant information on children, provide child care and family support services with the
aim of helping parents to care for their children and avoiding the need for such children
to be taken into care.
Under the Children Act 2001, which deals with children found in breach of the criminal
justice system, where the court is satisfied that ‘a wilful failure of the child’s parents to
take care of or control the child contributed to the child’s criminal behaviour’, a ‘parental
supervision order’ may be issued, requiring the parents of the child, to undergo, among
other things, treatment for alcohol or other substance abuse.
12.4
Responses
12.4.1 Availability of responses addressing the needs of drug using
parents/pregnant women and their children
Pregnant opioid users
In 1999 a specialist Drug Liaison Midwife (DLM) post was created in each of Dublin’s
three maternity hospitals (Scully, Mike, et al. 2004, Scully, M. , et al. 2001). The DLM
provides sessions in the maternity hospitals and in community-based addiction centres.
The aim is to ensure opiate using women engage with antenatal and drug services, to
stabilise them on methadone and to address health and social care issues.
After an initial assessment, the DLM immediately offers those women not in treatment
a treatment place depending on their needs. The mainstay of treatment is methadone
maintenance: stabilisation of drug use is stressed and women are encouraged to
remain on oral methadone throughout their pregnancy. The option to detoxify after the
172
first trimester exists, but women are not pressured to reduce dose or to detoxify. Those
who had difficulties stabilising are offered inpatient admission to a specialist drug
dependency unit.
Reviews of the DLM service (Scully, Mike, et al. 2004) (Carmody, et al. 2011) have
confirmed the importance of early intervention by the DLM and good communication
and working relationships between the maternity and addiction services as a means of
improving the service offered to the patients. The DLM service also appears to have
lessened the stigma associated with this group of patients.
Prisoners with babies and/or children
A report (Enright, et al. 2007) on babies in the Dochas Centre, the women’s prison
within Mountjoy Prison, Dublin, reported that imprisonment of mothers was avoided in
Ireland by means such as delaying sentencing, arranging temporary release or through
court appeal. If a pregnancy was only diagnosed on admission, antenatal care was
undertaken in conjunction with a hospital chosen by the patient. The woman was
encouraged to be drug-free. Some mothers had HIV and were treated with AZT during
their pregnancy and after. The baby’s HIV status was also checked. Parenting courses
were offered to the women. Enright and colleagues identified two options for improving
the quality of care for mothers and their babies in prisons: a mother and baby unit to
safeguard the child, and better links with community care so that the baby or child’s
development, social circumstances and health are known outside the prison and the
way can be prepared for a planned discharge into a safe environment with their
mother.
With regard to the care of children of drug users who are imprisoned, two studies of the
families of prisoners ((King, Dervla 2002) and (Bedford Row Family Project 2007))
found services for children with a parent or close relative in prison under-developed
and reported a lack of awareness about the effects of imprisonment on the children of a
prisoner among professional groups. They called for the needs of children and young
people affected by having a parent or sibling in prison to be incorporated into existing
training programmes; the establishment of support groups for children; the drawing up
of guidelines for parents on informing children about a parent’s prison sentence; and
the provision of services such as bereavement counselling, self-help groups and
activity-based group events, such as excursions.
The Irish Prison Service’s Health care standards (Irish Prison Service 2009) state that
drug use is not a reason to introduce care proceedings but that the needs of young
children of drug dependent parents should be considered of paramount importance.
Workers in methadone programmes are advised to include the care of children in their
treatment plan and have some means of supervision.
Parents attending drug treatment who have children
The Drug Treatment Centre Board (DTCB), Dublin, provides an example of the service
provided for children while their parents attend a drug treatment centre. A multidisciplinary social work team, including community care and probation professionals,
focuses on family support (including child welfare), advocacy, group work, writing
reports and attending inter-agency meetings. A children’s playroom provides
stimulation and a safe and supportive child-centred setting for children aged between 1
and 14 years, who accompany their parents/guardians to the clinic. They also offer
advice and support to parents who may have childcare concerns.
Parents in residential treatment who have children
The Coolmine Therapeutic Community (CTC) is the only residential service in Ireland
to provide a service for the children of parents living in the residential community. At
Ashleigh House, CTC provides a residential drug and alcohol rehabilitation service for
up to 14 women for a maximum of six months. Most women who come to Ashleigh
House have children. CTC reports that client feedback has revealed that one of the
barriers to women with children coming into the residential programme has been their
173
worry about breaking their emotional attachment with their children and that, if facilities
were provided for children to live on-site with their mother, the mothers would be better
supported as their children’s personal development could be strengthened through
specialist counselling and child welfare initiatives for children of primary school age.
With accommodation for children up to the age of 10, CTC is currently seeking funding
for services to support mothers staying in Ashleigh House in the care of their children,
including a crèche, after-school classes for children of primary school age, parenting
skills classes for those who need support, and one-to-one counselling for children who
have been affected by their mother’s addiction.
Parents in contact with community-based drugs services who have children
Through the drugs task forces, a number of community-based services provide
services targeted at the children of drug users. Just three examples are noted here,
highlighting the variety of responses.
The Ana Liffey Drug Project (ALDP), a ‘low threshold–harm reduction’ service, works
as one integrated multi-disciplinary project team, enabling it to focus on two key client
groups – single people affected by problem substance use, and families. Its Family
Care and Case Management Service aims ‘to promote and support high quality
parenting and to enhance the quality of life for children whose parents use drugs’.
SAOL is a community-based educational and rehabilitation day programme for women
in treatment for drug addiction. In order for women to access appropriate services,
SAOL provides a full-time childcare facility and early education programme for their
children – SAOL Beag (Little SAOL) Children’s Centre. Using an individualised
curriculum and approach to work with the children, the programme seeks to identify
each child’s interests, strengths and learning goals and to plan activities and learning
experiences for the child. An integral part of this service is to work in partnership with
the parents. Another key element is the relationship the children have with the adults
who work with them: the staff are qualified and experienced in dealing with children and
aim to form strong, caring relationships with the children. The SAOL Beag curriculum
has been developed in order to address the specific needs of children living with
addiction. It incorporates elements of Montessori, High/Scope and Birth to Three
Matters.
Ballyfermot Advance Project, associated with the Ballyfermot Local Drugs Task
Force, manages a Support for Childcare Fund, the purpose of which is to ensure that
people do not see childcare as a barrier to accessing treatment, rehabilitation or
aftercare programmes, by subsidising their childcare costs. An evaluation has shown
that the Fund has yielded benefits not only for the drug-using parents in need of
childcare but also for their children and family members. Benefits for children were
found to include childcare providers being more receptive to children from the target
group accessing their service, and children being better prepared and ready to access
mainstream primary education.
Drug-users experiencing difficulties in caring for their children
The Department of the Minister for Children and Youth Affairs (DMCYA) manages a
Prevention and Early Intervention Programme for Children, which is being piloted for an
initial five years. The programme includes three projects in three severely
disadvantaged areas in the Dublin region.23 Prevention and early intervention with
children is believed to be most successful when nested within supports for families –
providing parents, who are experiencing difficulties, including drug and alcohol use,
with the personal resources and skills they need. These projects will be evaluated and
provide an important input to policy and service development.
23
Further information on the three projects may be found at the following web sites: ‘A place for children in Tallaght
West – Childhood Development Initiative’ www.connect.southdublin.ie/cdi/index.phpp ; ‘Preparing for life (PFL) –
Northside Communities of Belcamp, Darndale and Moatview www.preparingforlife.ie/ ;and ‘Young Ballymun.
www.youngballymun.org/ .
174
In a separate study of family support services and their capacity to respond to the drugrelated needs of clients (Watters and Byrne 2004), it was found that the majority of
family support services were not aware of the positive role they could play in
responding to and preventing drug, including alcohol, problems. The authors
recommended that this could be corrected by introducing training regarding drugs and
drug prevention into the curriculum of professionals working in and managing family
support services, and by increasing the awareness and knowledge among existing
family support services regarding family functioning and drugs prevention.
‘Hidden populations’ of children living with drug-using parents
Enda Egan (Egan 2010, 15 June), CEO of The Carers Association, Ireland’s national
voluntary organisation for and of family carers in the home, stated there is an urgent
need to contact young carers, including those looking after parents with drug or alcohol
addictions, and engage with them in a way that does not frighten them or their families.
Egan recommended the development of protocols and pilot projects to produce
systems of identifying and engaging with young carers, and the creation of a web site
that would provide information, outlining services and supports, for young carers and
allow them to interact with each other and develop support groups. He also noted that
generally engagement with young carers starts in the education system and getting
teachers involved. All the other organisations and agencies dealing with children right
across the country should also be included.
Following their study of the 20-year outcome for 55 pregnant women using opiates and
attending drug treatment, Whitty and colleagues (Whitty and O'Connor 2007)
suggested that drug-using parents and their children need ‘intensive long-term support
and treatment’.
Children ‘at risk’
The HSE has statutory responsibility for the welfare and protection of vulnerable
children,24 including children of drug-using parents, whose welfare may be cause for
concern or who may be at risk of abuse or neglect. The ‘spine’ of the HSE’s child
protection and welfare services is the social work department which respond to reports
of abuse, neglect or welfare concern.
The HSE provides a range of support services to families where a child’s welfare is
cause for concern, including therapeutic work, parent education programmes, homebased parent and family support programmes, child development and education
interventions, youth work and community development. Alternatively, a family welfare
conference service offers families and professionals the opportunity to meet together in
an equitable manner, sharing equal responsibility in planning and decision-making.
Where a child is deemed to be at risk of abuse or neglect, they may be placed in care
outside the home, either in foster care, residential care, or some other suitable setting
such as being placed with a relative; a care plan is drawn up for each such child.
Details regarding the proportion of children who come into contact with the HSE’s child
and family services because of their parents’ drug or alcohol use are not routinely
made available. However, some indications of the number giving cause concern or
being taken into care because of their parents’ substance use have emerged in recent
years.
 In 2006 it was reported that 661 Irish families were causing concern to the HSE’s
welfare services because of drugs or alcohol misuse (Ombudsman for Children’s
Office 2010).
 A study on the development of residential child welfare in Ireland since 1978 found
that between the mid-1990s and 2005 there was a ‘significant’ increase in the
number of children taken into care in response to the ‘abuse of drugs and/or
24
See Section 12.2.1 above for an account of the Child Care Act 1991, which sets out the HSE’s statutory obligations,
and Section 12.3.2 below for an account of the national guidelines, Children First, which set out how the law is to be
implemented.
175
alcohol’ by a family member (O'Sullivan 2009). The reasons for this increase were
not explained in the report.
Since 2008 the HSE has been overseeing a thorough review of services for children
and families (Health Service Executive 2011b). Reviews of the service had revealed
that different social work departments were using different definitions of welfare,
neglect and abuse, and while more welfare and support type referrals were received
than reports of suspected child abuse, the focus of interventions was on child
protection. This has had significance for service design and resource allocation, as
social work departments that focus on child protection cannot provide a more
preventative, early intervention family support type service to children and families
where need rather than risk is the issue. What research and practice experience have
demonstrated, however, is that unmet need often generates increased risk over time
(Task Force for children & family social services 2010).
The HSE’s intention is to rebalance services with an emphasis on primary prevention
and family support. Integrated children and family services will be whole-child/wholesystem focused; accessible; and connected with family and community strengths. A
Differential Response Model (DRM) is currently being piloted in the Dublin region: a
model such as this will enable social work professionals to respond more flexibly to
different types of notifications and help meet the particular care and protection needs
identified (Children Acts Advisory Board 2008). It is expected that over time this shift
will reduce the number of children who need to leave their families to be cared for in
alternative forms of care. This shift is in line with the recommendations made by Hogan
following her empirical research (described in Section 12.2.2 above) (Hogan,
2007#1598). She recommended that support services should be family-oriented and
designed to provide long-term support for families, with the capacity to provide
increased support during periods of particular vulnerability. She suggested that since
some parents and children cope well most of the time, an open door service might best
suit the needs of many parents and children.
12.4.2 Availability of guidelines addressing drug-using parents/pregnant women
and their children
Drug-using pregnant women
The Irish College of General Practitioners’ Guidelines for working with opiate users in
primary care (Irish College of General Practitioners 2008) includes a short section on
pregnancy, emphasising the need to stabilise the woman’s drug use during pregnancy.
If necessary, the woman should be offered admission to an in-patient unit for
stabilisation on methadone (pregnant women receive priority for inpatient admission).
The Irish Prison Service’s Drug treatment clinical policy (Irish Prison Service 2008)
states that during pregnancy it is advisable to stabilise the woman on methadone,
rather than attempt to detoxify. However, if a woman wishes to detoxify during her
pregnancy, it is recommended that it should be done after the 12th week of pregnancy
but before the 32nd week, to reduce the risk of premature labour. The Irish Prison
Service’s Health care standards (Irish Prison Service 2009) states that attracting and
maintaining pregnant prisoners in treatment services is vital, and also advises that
long-term methadone maintenance treatment is considered the best option for most
opioid dependent pregnant women.
Neonates of opioid dependent women
The Irish Prison Service’s Health care standards (Irish Prison Service 2009) advises
that neonates born to opiate dependent mothers who show symptoms of neonatal
abstinence syndrome can usually be cared for in a normal maternity environment on
condition that, in case of emergency, they can be transferred to special care units. If
medication is required, a range of opioid and non-opioid drugs can be used. An oral
morphine concentrate is the drug of choice and phenobarbitone may be used if the
176
mother has been taking other substances, such as benzodiazepines. Breast feeding is
encouraged not only because of its general advantages but also because some
methadone may pass to the baby in very low doses and this in turn may help to reduce
any withdrawal symptoms on the part of the baby. In case of HCV infection, the
benefits of breast-feeding should be reviewed. Finally, because pregnant women and
young mothers may suffer from severe guilt feelings, psychosocial care and
counselling is highly recommended.
Children of drug-using parents – their protection and welfare
Children first: national guidance for the protection and welfare of children (Department
of Children and Youth Affairs 2011) is a revised version of guidelines first published in
1999 (Department of Health and Children 1999). The revised document twice refers to
the heightened risk of neglect or maltreatment among children of parents who use illicit
drugs, and states that those working in the Mental Health and Addiction Services with a
person with a mental health or addiction problem must consider the welfare and safety
of any children in that person’s family and/or children in regular contact with the person,
and that the child’s needs must remain paramount. The guidelines also state that it is
essential that efforts are coordinated and that information is shared between
professionals. The government has also announced that it intends to introduce
legislation requiring all organisations to have duty to comply with the Children First
guidance (endnote ref. Fitzgeral 2011, 15 July).
In October 2011 the HSE’s National Office for Children published a Child Protection
and Welfare Practice Handbook to assist in the standard implementation of Children
First 2011 (Health Service Executive 2011a). In chapter 3 on ‘Social work procedures
and practice’, under the heading of ‘risk factors in child protection’, the handbook
includes three pages on parental substance misuse, including both alcohol and drugs.
This section lists key messages (16) from research on parental substance misuse, and
practice notes for the social worker, comprising a series of questions under the
following headings:
 Parenting and attachment relationship
 Living conditions
 Financial circumstances
 Potential for harm
 Social and environmental circumstances
 The outcomes for this child.
The revised Children First guidance outlines the objectives and preferred approach to
training for those working in child protection and welfare, including basic training with
regard to child care legislation, national and local agency policies, procedures and
protocols, and advanced-level training on policy and practice, for example, risk
assessment and working in partnership with parents/carers. Researchers who have
undertaken qualitative studies of the services provided to drug-using mothers in Ireland
in recent years have highlighted the need for a number of different strands to be
included in training.
In a qualitative study of professional workers’ perceptions of mothers who use illicit
drugs, Lane (Lane 2010) interviewed professionals in a variety of disciplines (public
health nurse, social worker, addiction counsellor, community drug worker and family
support worker) with regard to their views of drug-using mothers and of their own roles
in relation to these mothers. She also observed their approaches to service delivery
and their interactions with mothers who used drugs. She found differences in how
different types of professionals saw the drug-using mother and the role of the
professional. For example, the community drug workers tended to consider that drug
use and motherhood could be combined, providing supports were put in place, while
other professional groups regarded drug use and motherhood as mutually exclusive
categories. Moreover, with regard to taking children into custody, while community
drugs workers advocated keeping the child with the mother where possible, other
professional workers argued that the mother should not have custody of her child until
177
she had overcome her drug use. Lane recommended that training and education for
professional workers should include topics such as drug addiction, gender, identity
development and stigmatisation, ‘as there appears to be a lack of knowledge around
the underlying problems that drug using mothers experience’, and that in implementing
national policy on childcare, professional workers should support cross-disciplinary
conversations and mutual respect among the various professions to ensure consistent
and appropriate implementation of policy and guidelines.
The Children First guidance advises that professionals should resist the tendency to
deny, minimise or explain away any signs that a child is being harmed, for example
where other problems are present, such as unemployment, poverty, poor housing,
addiction, mental illness or isolation. The protection and welfare of the child must
always be the paramount concern. In her major qualitative study on the impact of a
woman’s drug use on her identity, status and role as a mother, Woods (Woods 2008)
called for a more nuanced and in-depth approach to the issues:
… drug treatment providers and social workers need to upskill with regard to
childcare and drug issues respectively; review their assessment practices and
constantly probe the assumptions they bring to the area in a reflexive and
reflective way. Ultimately this study suggests that responding to drug use and
motherhood in a formulaic or prescriptive manner is not possible and it is
reasonable to recommend that workers be more questioning and probing in
their responses, not just of the women’s parenting and mothering practices and
skills, but of their own therapeutic practices, beliefs and assumptions. (p. 281)
178
Part C
13.
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190
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The Pharmaceutical Society of Ireland (2010). Non-prescription medicinal products
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follow-up study. Psychiatric Bulletin, 31, 450-453. Available at
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Woods, M. (2008). 'Keeping Mum': a qualitative study of women drug users'
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of Community, Rural and Gaeltacht Affairs, Dublin. Available at
http://www.drugsandalcohol.ie/6267/
191
13.2



List of relevant databases available on internet
Central Statistics Office interactive tables Census 1996, 2002 and 2006
www.cso.ie
Hospital In-Patient Enquiry scheme data 2000–2008
www.esri.ie/health_information/hipe/
National Drug Treatment Reporting System interactive tables 2004–2008
drugsandalcohol.ie
For descriptions of relevant databases not currently available on-line, see introductions
to chapters 5, 6, and 7.
13.3
List of relevant internet addresses
http://aldp.ie
http://addictionireland.ie
http://www.ballyfermotadvance.ie/
http://www.citywide.ie
http://www.coolmine.ie/
http://connect.southdublin.ie/cdi/index.php
http://www.cso.ie
http://www.courts.ie
http://dialtostopdrugdealing.ie
http://www.drugs.ie
http://drugsandalcohol.ie
http://www.fsn.ie
http://www.garda.ie
http://www.hpsc.ie
http://www.hrb.ie
http://www.hse.ie
http://inef.ie
http://iprt.ie
http://www.irishprisons.ie
http://www.justice.ie
http://www.mqi.ie
http://www.nacd.ie
http://nuigalway.ie/hbsc/
http://www.poisons.ie
http://www.preparingforlife.ie/
http://www.probation.ie
http://www.saolproject.ie/
http://www.sphe.ie/
http://www.taoiseach.ie
http://www.youngballymun.org/
192
14.
Annexes
14.1
List of Standard Tables and Structured Questionnaires used in text
Standard Table 01
Standardised results and methodology of adult national population
survey on drug use
Standard Table 02
Methods and results of school surveys on drug use
Standard Table 05
Direct drug-related deaths/Drug -induced deaths
Standard Table 06
Evolution of direct drug-related deaths/Drug induced deaths
Standard Table 07/8 National/local prevalence estimates on problem drug use
Standard Table 09-1 Prevalence of hepatitis B/C and HIV infection among injecting
drug users: methods
Standard Table 09-2 Prevalence of hepatitis B/C and HIV infection among injecting
drug users
Standard Table 09-4 Notified cases of hepatitis C and B in injecting drug users
Standard Table 10
Syringe availability
Standard Table 11
Reports of drug law offences
Standard Table 12
Drug use among prisoners
Standard Table 13
Number and quantity of seizures of illicit drugs
Standard Table 14
Purity/ Potency at street level of some illicit substances
Standard Table 15
Composition of illicit drug tablets
Standard Table 16
Price at street level of some illicit substances
Standard Table 18
Overall mortality and causes of deaths among drug users
Standard Table 24
Access to treatment
Structured Questionnaire 23/29 Prevention and reduction of health-related harm
associated with drug use
Structured Questionnaire 27 P1
Treatment programmes
Structured Questionnaire 27 P2
Treatment Quality Assurance
Structured Questionnaire 32
Drug Policy, evaluation and coordination
TDI 34
TDI data
14.2
List of tables
Table 1.2.1.1 Status of bills relevant to the drugs issue currently before the Dáil
Table 1.3.1.1 Drug-related ‘key priorities’ in Towards recovery: programme for a
national government 2011-2016
Table 2.2.1 Lifetime, last-year and last-month prevalence of illegal drug use in
Ireland, 2002/3, 2006/7 and 2010/11
Table 2.2.2 Lifetime, last-year and last-month prevalence of cannabis use in Ireland,
2002/3, 2006/7 and 2010/11
Table 2.2.3 Lifetime, last-year and last-month prevalence of cocaine use (including
crack) in Ireland, 2002/3, 2006/7 and 2010/11
Table 2.2.4 Lifetime, last-year and last-month prevalence of ecstasy use in Ireland,
2002/3, 2006/7 and 2010/11
Table 2.3.1 Trends in lifetime and last year prevalence of cannabis use for schoolgoing boys and girls (10-17 years) 1998, 2002, 2007 and 2010
Table 2.3.2 Proportion of early school leavers (479) and school attendees (512)
using different substances, 2008
Table 2.4.1 Drug use and frequency in the last year for third-level students, Limerick
Table 3.2.1.1 Progress on actions in NDS to deliver universal prevention measures in
primary and post-primary schools, March 2011
Table 3.2.1.2 Methods used to evaluate SPHE in primary schools in 2007
Table 3.4.1.1 Mental health and behavioural problems among young people
presenting to the Child and Adolescent Mental Health Services
(CAMHS), November 2009
Table 4.2.1.1 Number of opiate users known, estimated number hidden, prevalence
estimate and population rate in Ireland, in Dublin and in the rest of
Ireland, 2006
193
Table 4.2.1.2 Estimated prevalence of opiate use in Ireland, in Dublin, and in the rest
of Ireland, 2001 and 2006
Table 4.2.1.3 Prevalence estimate by age, gender and place of residence, 2006
Table 4.3.1.1 Drugs most commonly used by service users, Simon Communities in
Ireland, 2011 (n=768)
Table 4.3.1.2 Substance misuse among HIV patients, Ireland and Australia, 2005
Table 5.2.1 Number of services participating in NDTRS by type of service provider,
2004–2009
Table 5.3.1
Deliverable outputs for drug-related services in 2011
Table 5.4.2.1 Types of service offered by MQI, the numbers of people accessing them,
and the outcomes, 2009
Table 5.4.3.1 Number of continuous care clients attending methadone treatment (on
31 December each year), CTL, 1998–2010
Table 5.4.3.2 Proportion of CTL registered patients who died, NDRDI, 1998–2007
Table 5.5.1 Benzodiazepine cases entering treatment by treatment status, NDTRS
2003–2008
Table 5.5.2 Proportion of poisonings where benzodiazepines were implicated,
NDRDI 1998–2007
Table 5.5.3 Main problem drug used by cases entering treatment (NDTRS 2004–
2009
Table 6.2.1.1 Blood-borne viral status in 61,030 singleton births at a large Dublin
maternity hospital, 2000–2007, by exposure to methadone
Table 6.2.3.1 Number (%) of attenders at a methadone treatment centre in Dublin with
abscess, by frequency of injecting cocaine or heroin (n=48)
Table 6.2.3.2 Number (%) of injecting drug users attending a methadone treatment
centre in Dublin, by sharing injecting equipment and frequency of such
sharing (n=70)
Table 6.3.1.1 Category of drugs involved in overdose cases, 2009 (N=4,172)
Table 6.3.1.2 Category of drugs involved in intentional overdose cases, 2009
(N=2,879)
Table 6.4.1.1 Poisonings (Selection D) by year, NDRDI, 1999 to 2009 (N=1681)
Table 6.4.1.2 Alcohol-related poisoning deaths (NDRDI 2004–2008) (N = 671)
Table 6.4.1.3 Additional drugs involved in alcohol polysubstance poisoning deaths
(NDRDI 2004–2008) (N = 341)
Table 6.4.1.4 Drugs involved in all poisoning deaths in Ireland (NDRDI 2004–2008)
(N=1,650)
Table 6.4.3.1 Drug-related deaths, by year of death, NDRDI 1998–2008 (N=4,064)
Table 8.2.1.1 Prevalence of social exclusion among all case reporting for drug
treatment, 2005-2010
Table 8.2.2.1 Lifetime and recent (past 3 months) illicit drug use among people
recruited through drug treatment centres in the Canal Communities,
Dublin, data collected in 2008
Table 8.3.3.1 Number of participants, and range of Ready for Work activities, 2002–
2011
Table 8.3.3.2 Number of participants engaged in RFW activities during last quarter of
2010
Table 9.2.1.1 Sentences for drug offences in the District Court, 2010
Table 10.3.1.1 Particulars of all drugs seized in 2010 that were reported on by the FSL
Table 10.4.3.1 Drug seizures in Irish prisons, January 2009–September 2010
Table 11.1.1 Bed capacity (BC) and numbers in custody (NIC) in Irish prisons, 23 July
2010
Table 11.1.2 Substances involved in deaths by poisoning within the first month of
release from prison (n=38), NDRDI 1998–2005
Table 11.4.1 Treatment options available by prison, September 2010
Table 11.4.2 Number of cases attending methadone treatment in prison, 31
December 2010
Table 12.2.1.1 Blood-borne viral status among methadone-exposed mothers, among all
singleton births at CWIUH, 2000–2007
194
Table 12.2.2.1 Methadone dose and its relationship with neonatal abstinence syndrome
among methadone-exposed mothers, among all singleton births at
CWIUH, 2000–2007 (n=615)
14.3
List of figures
Figure 2.3.1.1 Trends in lifetime and last year prevalence of cannabis use for schoolgoing children by age, 1998, 2002, 2007 and 2010
Figure 6.2.1.1 Actual number and rolling average number of new cases of HIV among
injecting drug users, by year of diagnosis, reported in Ireland, 1986–
2010
Figure 6.3.1.1 Overdose cases by year, 2005–2009 (N=23,714)
Figure 6.3.1.2 Overdose cases by gender, 2005–2009 (N=23,714)
Figure 6.3.1.3 Overdose cases by age group, 2005–2009 (N=24,314)
Figure 6.3.1.4 Narcotics and hallucinogens involved in overdose cases, 2009 (N=539)
Figure 6.3.1.5 Overdose cases by classification, 2009 (N= 4,096)
Figure 6.3.2.1 Rates of psychiatric first admission of cases with a diagnosis of drug
disorder (using the ICD-10 three-character categories) per 100,000 of
the population in Ireland, NPIRS 1991–2009
Figure 6.4.3.1 Deaths due to medical or traumatic causes among drug users, NDRDI,
1998 to 2008 (N = 1630)
Figure 9.2.1.1 Trends in relevant legal proceedings for total drug offences, drug
possession for personal use and for supply, 2004–2009
Figure 9.2.2.2 Trends in relevant legal proceedings for selected drug offences, 2004–
2009
Figure 9.2.3.3 Trend in relevant legal proceedings for driving in charge of a vehicle
while under the influence of drugs, 2005–2009
Figure 10.2.1.1 Trends in relevant legal proceedings for possession of drugs by Garda
region excluding the Dublin Metropolitan Region 2003–2009
Figure 10.2.2.2 Trends in relevant legal proceedings for possession of drugs for the
Dublin Metropolitan Region and total possessions for the State 2003–
2009
Figure 10.3.1.1 Trends in the total number of drug seizures and cannabis seizures,
2005–2010
Figure 10.3.1.2 Trends in the number of seizures of selected drugs, excluding
cannabis, 2003–2010
Figure 11.1.1 Relationship between date of release from prison and drug-related death
(n=89), NDRDI 1998–2005
Figure 12.2.1.1 All-Ireland General Population Drug Prevalence Survey, 2006/7:
Lifetime and last year drug use prevalence, by drug, among respondents
with dependent children aged 18 or younger
Figure 12.2.1.2 All-Ireland General Population Drug Prevalence Survey, 2006/7:
Comparison of demographic characteristics of respondents with
dependent children aged 18 or younger who had ever used or had used
in the last year
Figure 12.2.1.3 All-Ireland General Population Drug Prevalence Survey, 2006/7:
Comparison of occupational status of respondents with dependent
children aged 18 or younger who had ever used or had used in the last
year
Figure 12.2.1.4 Proportion of clients in drug treatment who live with children, by
gender, 2003–2009
14.4
List of maps
Map 10.1.1: Irish Garda regions and divisions
14.4
List of legislation
Laws
195
Communications (Retention of Data) Act 2011
Criminal Justice (Public Order) Act 2011
Road Traffic Act 2011
Criminal Justice (Money Laundering and Terrorist Financing) Act 2010
Criminal Procedure Act 2010
Road Traffic Act 2010
Criminal Justice (Psychoactive Substances) Act 2010
Statutory Instruments
Misuse of Drugs Act 1977 (Controlled Drugs) (Declaration) Order 2010 (S.I. 199 of
2010)
Minister for Health and Children signed the Misuse of Drugs (Amendment) Regulations
2010 (S.I. 200 of 2010)
Misuse of Drugs (Designation) (Amendment) Order 2010 (S.I. 201 of 2010)
Misuse of Drugs (Exemption) (Amendment) Order 2010 (S.I. 202 of 2010)
Bills
Criminal Justice (Community Service) (Amendment) Bill 2011 (No 12 of 2011)
Spent Convictions Bill 2011 (No 15 of 2011)
Criminal Justice Bill 2011 (No 16 of 2011)
14.5
List of abbreviations
ADHD
ADRU
AGPAR
AIDS
ALDP
AUDIT
BAC
B&B
BBV
BITC
BZP
CAAB
CAB
CAMHS
CAN
CAPE
CCA
CCLDTF
CDLE
CE
CGES
CHIS
CLAN
CPAD
CSO
CTC
CTL
CWIUH
DAIRU
DAG
DCEGA
DCRGA
DCYA
Attention-Deficit Hyperactivity Disorder
Alcohol and Drug Research Unit
Activity, Pulse, Grimace, Appearance, and Respiration
Acquired Immunodeficiency Syndrome
Ana Liffey Drug Project
Alcohol Use Disorders Identification Test
Blood Alcohol Content
Bed and Breakfast
Blood Borne Virus
Business in the Community Ireland
Benzylpiperazine
Children Acts Advisory Board
Criminal Assets Bureau
Child and Adolescent Mental Health Service
Swedish Council for Information on Alcohol and Other Drugs
Community Assessment of Psychic Experiences
Court of Criminal Appeal
Canal Communities Local Drugs Task Force
Customs Drug Law Enforcement
Community Employment
Children’s Global Assessment Scale
Central Human Intelligence System
College Lifestyle and Attitudinal National Survey
Concerned Parents Against Drugs
Central Statistics Office
Coolmine Therapeutic Community
Central Treatment List
Coombe Women and Infants University Hospital
Drugs and Alcohol Information and Research Unit (DHSSPS, NI)
Drugs Advisory Group
Department of Community, Equality and Gaeltacht Affairs (since
March 2010)
Department of Community, Rural and Gaeltacht Affairs (before
March 2010)
Department of Children and Youth Affairs
196
DES
DES
DEHLG
DEIS
DHSSPS
DLM
DMCYA
DML
DMR
DNE
DSH
DoH
DoHC
DRM
DTC
DTCB
DTF
DUID
ED
EMCDDA
ESL
ESPAD
ESRI
EU
FÁS
FETAC
FSL
FSN
GARF
GBL
GMS
GNDU
GP
GYDP
HADS
HBSC
HCV
HIV
HIPE
HPSC
HRB
HSCL
HSE
ICGP
ICU
ICP
IDO
INEF
IPRT
IPS
ISM
IYJS
JPC
LDTF
LGBT
LPF
MAOC-N
MAP
MCIDI
Department of Education and Science (before March 2010)
Department of Education and Skills (since March 2010)
Department of the Environment, Heritage and Local Government
Delivering Equality of Opportunity in Schools
Department of Health, Social Services and Public Safety
Drug Liaison Midwife
Department of the Minister for Children and Youth Affairs
Dublin/Mid Leinster
Dublin Metropolitan Region
Dublin/North East
Deliberate Self Harm
Department of Health
Department of Health and Children
Differential Response Model
Drug Treatment Court
Drug Treatment Centre Board
Drugs Task Force
Driving Under the Influence of Drugs
Electoral Division
European Monitoring Centre for Drugs and Drug Addiction
Early School Leavers
European School Survey Project on Alcohol and Other Drugs
Economic and Social Research Institute
European Union
Foras Aiseanna Saothair (Training & Employment Authority)
Further Education and Training Awards Council
Forensic Science Laboratory
Family Support Network
Global Assessment of Relational Functioning DSM-IV
Gamma butyrolactone
General Medical Services Payment Board
Garda National Drugs Unit
General Practitioner
Garda Youth Diversion Project
Hospital Anxiety and Depression Scale
Health Behaviour in School-aged Children Survey
Hepatitis C Virus
Human Immunodeficiency Virus
Hospital In-Patient Enquiry scheme
Health Protection Surveillance Centre
Health Research Board
Home School Community Liaison
Health Service Executive
Irish College of General Practitioners
Intensive Care Unit
Integrated Care Pathway
Intentional Drug Overdose
Irish Needle Exchange Forum
Irish Penal Reform Trust
Irish Prison Service
Integrated Sentence Management
Irish Youth Justice Service
Joint Policing Committee
Local Drugs Task Force
Lesbian, Gay, Bisexual and Transgender
Local Policing Fora
Maritime Analysis and Operational Centre – Narcotics
Maudsley Addiction Profile
Munich-Composite International Diagnostic Interview
197
MHC
MDA
MDT
MTP
MQI
MRSA
MRSSA
NACD
NAS
NAPS
NDS
NDRDI
NDRIC
NDTRS
NEWB
NGO
NMPDU
NPIC
NPIRS
NPIS
NRP
NSP
NUI
OFD
OECD
OMCYA
OMD
OTC
PCCC
PCRS
PFL
PHIRB
PISA
PSI
PQ
PULSE
QFI
QuADS
RAPID
RDTF
ROSIE
SAOL
SBCU
SCP
SDS
SFP
SLA
SLÁN
SMART
SPHE
STI
TCD
TD
TDI
TR
UCC
UCD
UK
VEC
Mental Health Commission
Misuse of Drugs Act
Mandatory Drug Testing
Methadone Treatment Protocol
Merchants Quay Ireland
Staphylococcus aureus
Staphylococcus aureus
National Advisory Committee on Drugs
Neonatal Abstinence Syndrome
National Anti-Poverty Strategy
National Drugs Strategy
National Drug-Related Deaths Index
National Drugs Rehabilitation Implementation Committee
National Drug Treatment Reporting System
National Education Welfare Board
Non Governmental Organisation
Nursing and Midwifery Planning and Development Unit
National Poisons Information Centre
National Psychiatric Inpatient Reporting System
National Poisons Information Service
National Reform Programme
National Service Plan (of the Health Service Executive)
National University of Ireland
Oversight Forum on Drugs
Organisation for Economic Co-operation and Development
Office of the Minister for Children and Youth Affairs
Office of the Minister for Drugs
Over-the-counter
Primary, Community and Continuing Care
Primary Care Re-imbursement Service
Preparing for life
Public Health Information and Research Branch
Programme for International Student Assessment
Pharmaceutical Society of Ireland
Parliamentary Question
Police Using Leading Systems
Quality Framework Initiative
Quality in Alcohol and Drug Services
Revitalising Areas by Planning Investment and Development
Regional Drugs Task Force
Research Outcome Study in Ireland
Service Provision for Women with Addiction Problems
Special Baby Care Unit
School Completion Programme
Severity of Dependence Scale
Strengthening Families Programme
Service-level Agreement
Survey of Lifestyle, Attitudes and Nutrition in Ireland
Standardised Measurement of Alcohol Related Troubles
Social, Personal and Health Education
Sexually Transmitted Infection
Trinity College Dublin
Teachta Dála (Member of Parliament)
Treatment Demand Indicator
Temporary Release
University College Cork
University College Dublin
United Kingdom
Vocational Education Committee
198
VTR
WHO
YHS
YPFSF
Vertical Transmission Rate
World Health Organization
Youth Homelessness Strategy
Young People’s Facilities and Services Fund
199